Surgical tools and methods for their use

ABSTRACT

Surgical tools and kits for performing methods include a grommet with cylindrical shaft, cutting tip, annular flange with suture retaining anchoring fixture; a grommet jig for extending between adjacent grommets and guiding a needle therebetween; a family of needles with single and double pointed ends, reinforced eyelets, stops to limit inadvertent exiting, double shaft construction with a longitudinal gap and sharpened, slicing ends, including a “J” shape embodiment; a bone anchor with ring to secure sutures about a patient&#39;s clavicle; a tissue dissector having radially extending cones to nick taut connecting tissues; a tissue rasp having a series of crisscrossing grooves along an end; a tissue mesher comprising one or more blocks having a matrix of holes for clamping a plurality of needles and a supporting framework; and a kit device and a method of surgically inserting an internal mesh brassiere under the breast skin.

BACKGROUND AND SUMMARY OF THE INVENTION

The inventor has conceived of, reduced to practice, and patented, manyinventions related to the augmentation of soft tissue includingespecially the augmentation and reconstruction of the female breast.Several examples of his patented inventions include the following: U.S.Pat. Nos. 5,536,233; 5,662,583; 5,676,634; 5,695,445; 5,701,917;6,083,912; 6,478,656; 6,500,112; 6,641,527; 6,699,176; and most recentlyU.S. Pat. No. 8,066,691, along with other patent applications underprosecution such as 20080167613, 20100137841, and 20100160900, thedisclosures of all the foregoing being incorporated herein by reference.As his investigative work has continued, he has continued to inventtools and methods for their use which enable him to implement newsurgical procedures which provide strikingly improved results for hispatients over existing practices and procedures implemented by othersurgeons in this field. Many of these may be implemented together andthus provide the basis for them to be provided in a kit, either singleuse or for repeated use with one or more patients. Similarly, several ofthese may be implemented not only together but also in conjunction withthe tools and methods of his earlier work as exemplified in his patentfilings mentioned above. Furthermore, several of inventions disclosedherein, while implemented by the inventor and having been found to work,have alternate constructions or embodiments that the inventor hasconceived of and which are contemplated to also work and may even bemore desirable for commercialization. These tools and appliances may bebriefly summarized as follows.

A number of the inventions described, infra, are useful in a particularbreast augmentation/reconstruction procedure or a procedure for thecorrection of breast deformities, whether acquired or congenital, whichwill be described in greater detail below as part of the DetailedDescription of the Preferred Embodiments and illustrated in the drawingsincluded herein. The inventor has coined the term Reverse Abdominoplastyand Lipo-Filling (RAFT) to describe this procedure which is a minimallyinvasive alternative method of breast reconstruction that utilizes theanterior abdominal apron as a reverse abdominoplasty flap. The RAFTprocedure was initially developed as a means of salvaging the failedimplant augmentation and reconstruction procedures and the inventorlater realized that it was also a very useful means of augmenting thesmall breast, of correcting the breast deformities, or treating scars orchest wall wound defects, and of reconstructing mastectomy defects.Essentially, it comprises a purse string suture that can be threadedthrough the dermis/subdermal tissue layers of the abdominal skin apronthat is to be advanced and incorporated into the breast, and a mechanismto suspended this suture to the clavicle to secure the advancement, andto tighten it in order to induce a mushrooming out projection of thebreast and to sculpt a pleasing inframammary and lateral breast folds.The abdominal apron to be advanced is usually first filled with atumescent fluid and liposuctioned to loosen it and deflate it. This isfollowed by extensive percutaneous dissection to create an interface toensure long term maintenance of the suspension and the repositionedtissue independent of the suture. The advanced abdominal and lateralthoracic flaps by themselves add significant volume to the breast mound.Lipofilling the breast and the purse-stringed advanced flaps adds morevolume and shape to created breast mound. Percutaneously meshing thedeeper retaining structures that restrict the advancement of theabdominal apron expands it (similar to a skin graft mesh expansionpattern) and alleviates the tension. It also serves to divide thecutaneous perforator nerves that would normally cause pain if they arestretched but usually not if they are simply divided. As shown in FIG.41, use of the tissue mesher allows for further advancement of theabdominal skin apron. The reconstruction is with local breast-liketissue, is incisionless, minimally invasive and patient friendly. It isconsidered by the inventor as a first choice reconstructive option thatis also available when all else has failed or in some cases not eventried. Though most useful for the breast, the same principle of tissueadvancement and tightening can be applied to other anatomic areas suchas the jowls of the aging face and the overhang of the panniculus orother anatomic structures that migrate downward under the effect ofgravity with aging and volume loss.

The reconstruction of a woman's breast is an important step towards herrecovery after mastectomy or following other disfiguring breastpathologies. The TRansverse Abdominoplasty Musculocutaenous flap or TRAMflap as it is most commonly called, is one of the most common methods ofachieving this purpose. It consists of performing an abdominoplasty(tummy tuck) and then transferring the harvested excess abdominal tissueto the chest as a flap. Unfortunately, the TRAM flap is a major surgicalprocedure that carries a substantial amount of morbidity, inflictsmultiple incisions and has a significant failure and complication rate.While the abdominal tissue is the best available substitute for therestoration of a breast mound, a more patient friendly, less invasiveand less complication prone method of transferring this tissue to thebreast would provide a significant societal benefit.

While both the TRAM and the novel method described herein take advantageof the laxity of the abdominal apron, compared to the TRAM where thetissue is totally cut out of the lower abdomen and brought up to thechest, this device allows the lax abdominal tissue to slide up, to besecured in its new position and to be molded into a breast withouthaving to cut it out and without any major incision. The inventionherein preferably comprises a kit for use by a surgeon to perform asurgical procedure to transfer the abdominal tissue to the chest bysliding it up and fixing it in place with a purse string of suture, andthe fashioning of that tissue into a breast mound by filling it with asmall implant or with a suitable fluid such as aspirated fat. The kitcomponents provide means of:

-   -   1—Mobilizing the laxity of the upper abdominal tissue to slide        it up to the breast,    -   2—Inserting a suspension suture that is threaded from the level        of the upper chest or the clavicle, down to the upper abdominal        tissue, where it can grab its dermis/subcutaneous tissue in a        purse string fashion and then thread it back up to the level of        the upper chest or clavicle to close the loop.    -   3—Using that suspension suture to grab the abdominal tissue,        pull it up and suspend it to the clavicle (collar bone) with a        bone anchor.    -   4—Tightening the suture to pucker the purse string into a dome        and firmly securing the looped suture to the bone anchoring        device using a suture locking mechanism    -   5—Percutaneously dividing the fibers that restrict advancement        of the skin just cephalic (above) and caudal (below) to the        purse string to allow a “mushrooming effect” and fully define        the breast overhang and the breast fold.    -   6—Without making a skin incision and only through a multitude of        non-scar inducing punctures, cutting the deep tissues at the        level of the new fold to define it and to induce it to        permanently heal and adhere in that new location    -   7—Loosening the resultant tightness of the rest of the abdominal        tissue by mesh expanding it and dividing the restrictive        vertical retaining fibers and perforators as shown in FIG. 41.    -   8—Filling the advanced tissue with fat graft and percutaneously        re-orienting its fibrous framework in order to correct any        puckering, iron out wrinkles and treat the “double bubble”        deformities.    -   The steps described above are not necessarily performed in the        order presented.

The kit components could be single use, sterile, disposable, or morepermanent re-usable & re-sterilizable. Some of these components couldcome inside a box kit for a specific application or can be madeavailable as individual devices. While, as known to the inventor, eachof these components is novel and serves a specific purpose for use inperforming a RAFT breast reconstruction, they are most likely useful inother related or unrelated medical applications such as the rejuvenatingface lift and other procedures that benefit from advancing tissue beyondwhat the normal tissue laxity and mobility permits.

One of these inventions may best be characterized as a temporary bra, tobe used, as appropriate, throughout the surgical process but mostpreferably during surgery and then post-operatively to maintain theshape and to prevent any recoil of the swollen tissue. This bra issterile and may be applied during surgery. The bra is preferablytransparent, sufficiently pliant to conform to the breast surface andthen preferably molded to the desired shape as it is preferably stronglyadhered to the skin. The adhesive component may be inherent to the braor shaping device material so that it adheres upon initial contact orthe shaping device may not be initially adherent as this will allow thebreast (or other anatomic region) to be appropriately positioned insidethe device and then, when appropriately arranged inside the shaping bra,the adhesive component might be added or made to become active. Thedevice may also have suspension straps or a cap bonnet to overcome theeffect of gravity. It may have a pattern of markings on it to mark thepath of the sutures and the position of the grommets (see below) toguide the surgeon as he performs a surgicallifting/shaping/augmentation/reconstruction on the breast. This bra mayalso include a rib like structural reinforcement to help hold its shapeas it is worn by the patient. Alternatively, the shaping device itselfmight be made of a material that hardens upon exposure to air or to acatalyst, or a hardening component can be added to it as desired by thesurgeon.

To further aid the surgeon as he threads sutures through the breast, theinventor has developed several grommet designs which fit through thedermal tissues (and bra, if used) to identify and isolate exit pointsfor the sutures which aids in not only avoiding damage to anysuperficial subdermal fibers and invagination dimpling of the skin whenthese superficial fibers are inadvertently held by the suture and driveninside by its tightening, but also assists in creating an internal weaveset at a predetermined depth to support and lift the breast in a novelsurgical procedure developed by the inventor.

Thanks to the grommet, a surgeon can pass the entire needle out throughthe skin, then pass the thread through the grommet, secure the grommetin place through and over the skin puncture site, and re-enter with thesingle pointed needle through the same entrance path to avoid grabbingdermal fibers and thus grab only the deep tissues and avoid the unwanteddimpling effect which would potentially be created in the dermal tissuesadjacent the exit/entry point. The grommet could thus be a “salvage” forthe double pointed needle as re-entry of the needle through a grommetthreaded over the thread that has exited will prevent that suture loopfrom grabbing unwanted superficial tissues.

The grommet provides an elegant alternative to the double pointed needleas may otherwise be required. A grommet can be inserted first throughthe skin around the area that needs to be suspended and then twoseparate needles at the ends of the same thread can be passed through,each circumscribing a separate path. Removing the grommet and tighteningthe suture buries the loop deep inside the tissue (at the predetermineddepth of the grommet) without grabbing dermal fibers and puckering theskin.

In addition, having two separate thread loops, each with a differentpath, exit through the same grommet allows these loops to interlock andcreate a basket weave that can be driven deeper inside the breast (orother anatomic areas chosen for the procedure) without puckering theskin and without leaving a significant scar. A judiciously placedpattern of grommets and thread paths is a unique and novel method ofpercutaneously weaving a net-like or basket weave like supportive andshaping mesh pattern deep inside the tissues without making any majorincision, only tiny puncture sites that tend to heal without asignificant scar. To prevent an unwanted exit through the skin and keepthe grommet securely in and across the skin opening while the needlesand threads are coming in and out, the grommet preferably has astructure to hold it in place. To this effect, the grommet may havethreads like a screw so that it may be screwed in place. Alternatively,the grommet could simply have a button like or barb like design on theentry side that prevents its unintended withdrawal, or include aretractable, telescoping “fanning out” umbrella that would open on theundersurface of the skin to hold it tightly in place. This additionallocking mechanism would enter the skin through the same hole, however,for the sake of keeping the hole at minimal size, the anchoringmechanism could be spaced about a top hat or flange in the grommet thatgrabs the skin through separate fine needle sticks, fine clamps, astaple like mechanism or even sutures. As yet another feature of thegrommet, a cleat or spiral hook may be provided to allow a suture tostay outside and be anchored and then reintroduced into the patient'sbreast after interlocking it with another loop that also exited throughthe same grommet so as to create the basket weave internal support braprocedure described, infra and in other of the inventor's patentfilings.

As an adjunct to the grommet invention, the inventor has also conceivedof a jig or guiding mechanism that can be attached between two or moreadjacent grommets and used to physically guide the needle as it isinserted and extends between the two grommets. A pattern of jigs can beaffixed to the supportive bra or other shape forming device to guide theentire process of inserting and weaving the mesh. This assists thesurgeon in the delicate procedure of guiding the needle through the deeptissues and then the intradermal tissues of the patient as one of thesurgical procedures described herein is performed. Again, although notstrictly required, it helps transform the process from one of art toscience to thereby improve chances for a successful procedure.

The inventor has conceived of and developed a number of needle devicesto aid him in several of his novel surgical procedures. Among these area needle that can be driven from a distance to enter from one site, graband secure tissues that are relatively distant, and return to theoriginal entrance point while keeping the suture deep within the bodytissue without grabbing of any intervening skin and without causing anyunwanted puckering. This requires a needle that is significantlydifferent than the standard surgical needles that are used to stitchtogether wounds or immediately exposed adjacent structures.

The needle preferably has a sharp point at only one end as long as longas the procedure allows it to come in and out only through “mature”puncture holes along its looped course. Mature holes may be for exampleliposuction cannula entry holes that have their subdermal fibersdestroyed by the repeated passage of the cannula such that an in & outpassage of the needle through this widely dissected path is not likelyto catch unwanted fibers along the way. In a surgical procedure such asthe fat graft augmentation typically performed on a patient with excessabdominal fat, a liposuction procedure to harvest the fat for use in thebreast augmentation would provide these mature holes, for example.

Most prior art surgical needles have pointed tips that are round incross section. The inventor's needle invention preferably includescutting tips; needle tips having a cross section with sharp cuttingedges at the pointed end to slice through the dermis. (Surgical needlesare normally classified as having either round or cutting tips.) Theneedle here preferably needs to have a extremely sharp and long beveledcutting tip that has preferably an even sharper finer bevel to slicethrough the arcuate long dermal path when it is used for the pursestring procedure described, infra). Furthermore the orientation orneedle cutting tips should ideally be such that the cuts are deep andalong the inner curve and not up, as explained infra.

Another needle embodiment is preferably double pointed. (Though for theRAFT procedure only one of the pointed tips is preferably very fine andcutting, the other, for the purpose of safer manipulation is preferablyround or with a shorter cutting bevel). Double pointed needles arecapable of being driven along a complex stitch course to grab and tietogether deep and far tissues (as contrasted with adjacent tissues as istypically done in the prior art) without the attached thread ever havingto exit through the skin which tends to cause unwanted dimpling. Aclassic prior art needle (sharp at one end and blunt with a threadthrough an eye at the other) can only be driven through the tissue for ashort distance, and this through a relatively straight course, or onethat circumscribes only a limited arc. To go through a lengthy course orto complete a loop and come back to its original entry site, a standardneedle has to exit the body every few centimeters, and be driven backagain through the skin to continue and complete the path. With thisprocess, as dictated by the typical prior art needle, it is difficult topenetrate the skin again back through the exact same exit pin hole, andeven if it does, it is even more difficult to follow the exact same pathalong the subdermal fibers. As a result, the thread that follows willinevitably grab some skin or some subdermal fibers along its in and outlooping path, and when tightened, the stitch will almost invariablycreate some dimpling of the skin at each entry/exit site. A doublepointed needle can be driven through the tissues with the first sharppoint forward like a conventional needle and have that first point comeout through the skin. But unlike the conventional needle, to continuethe complex course, the double pointed needle does not have tocompletely come out through the skin. If the second point is kept deepinside the tissue, that needle can now be handled by the outside shaftand driven back for another bite with the second point now forwardpiercing the tissues. One of non-obvious advantages enabled by thedouble pointed needle invention is that the attached thread neveremerges through the skin and instead remains at the depth predeterminedby the length of needle kept inside at each bite. This presumes acentrally located eye or thread connection site.

There are some prior art double pointed needles previously described byinnovative plastic surgeons and are called shuttle needles. This simpledesign of a straight double pointed needle with a hole for the thread inthe middle is known in the art. However, the present invention improvesupon this type of needle with a number of non-obvious designmodifications that provide many more functional advantages and whichadapt it to be especially useful for the purposes described, infra. Forexample, some of these differences include: Size: prior art length of10-15 cm vs. 25-50 cm for the invention & prior art diameter 0.8-1.2 mmvs. 1.5-3.5 mm diameter. Curvature: prior art straight or simple curvedarc vs. a relatively straight central portion with a curvature at one ifnot both ends for the invention. In one embodiment the needle preferablytakes a “J” shape, or in an another, a double “J” shape. Cutting point:prior art sharp point tip with round cross section vs. sharp point tippreferably with cutting sharp edges in cross section and a long bevelspecially oriented according to its curvature to allow it to slicethrough as it is tunneled inside the dermis without risk of cutting theskin surface along its path. In addition to being able to be driven froma long distance (from infraclavicular to upper abdominal), the needleused for the RAFT needs to maintain the suture in an even tissue planeas it is threaded through what becomes the mammary folds is consideredimportant by the inventor for desirable results. Otherwise, instead ofresulting in an even line fold, the purse-string tightening may resultin unsightly curtain like dimples, bulges and folds.

Malleability; prior art brittle hard vs. rigid but malleable enough soits path can be steered to a certain extent along its curved path fromthe outside, while it is handled from the distant exposed end as it ispushed through the tissues and manually steered externally along the arcand kept at the desired anatomical depth.

In addition to the above, the inventor conceives of a family of needlesthat may for convenience be categorized into the following types. Allare preferably curved and pointed on one or both sides. These areconsidered by the inventor as the improvements and the novel features tobe added to the simple double pointed needles previously described.

-   -   a—Eye or swaged thread insertion point closer to the needle        point edges: The previously described shuttle needles have a        simple hole for the thread (the eye) at the approximate        mid-point of the needle. This mechanically weakens the needle at        its very center where the torque is strongest while it is driven        through the patient, making it prone to breaking with a broken        piece deeply lodged and causing complications. To remedy that        shortcoming in the prior art, the inventor has conceived of an        alternate modification which places the eye close to one of the        sharply pointed ends so as to reduce the torque capable of being        applied as the needle may be grasped nearer the eye when        inserted, and thereby also reduce the chance of the needle        breaking at the eye. Most if not all previously described        shuttle needles have the eye, or the attachment point of the        thread, at the middle of the needle shaft. The inventor has made        the discovery that an eye close to the pointed edge still serves        the same purpose of being able to shuttle a stitch while        reducing the possible torque to be applied at the weak eye or        the suture insertion point and therefore greatly diminishing the        possibility of the dangerous complication of breaking the needle        in its middle with one of the halves deep inside the patient's        tissues.    -   b—Reinforcement of the needle at the eye or the swaged thread        insertion site: The second modification, regardless of the        location of the eye or suture insertion point, consists of        reinforcing the area around that weak spot to further inhibit        possible needle breakage. This reinforcement could preferably be        in the form of a metal sleeve around the eye opening, a        thickening of the needle shaft at that location, or a segment of        stronger alloy used at that particular location or otherwise.    -   c—Swaged thread design: For a single use device, a present day        requirement for all modern sutures, the swaged thread design is        the preferred embodiment. The thread can be connected at one end        for the single sharp end needle embodiment or on the shaft        somewhere between the two points with the reinforcement        described above for the double sharp end needle embodiment. The        thread material can also be molded around and through the needle        shaft for a more secure connection that does not weaken the        structural mechanical properties the needle.    -   d—Adjustable or Marked Exit/Pivot Point: For the double pointed        needle to maintain its suture thread deep inside the tissues and        avoid skin dimpling, it is presently considered by the inventor        to be critically important to always maintain one of the needle        point tips under the skin. The opposite point should not exit        the skin while the needle shaft is reloaded on the needle holder        and the needle shifts direction to advance and take the next        suture bite. This is delicate and trickier than it may seem, as        inadvertent minimal exiting of the second needle tip will        inevitably catch dermal fibers during re-entry, annul the        advantage of the double pointed needle and lead to failure of        that entire needle path. Furthermore, the depth at which the        needle switches direction to be driven forward again determines        the level at which the tissues are sutured. The problem becomes        even more delicate when the desired depth/level of tissue        suturing is more superficial or needs to be precisely set.        Simple prior art double pointed needles do not offer a mechanism        to prevent inadvertent exit and provide no means to gauge the        depth of the needle tip as the needle is withdrawn leaving the        surgeon guessing without any objective reference as to how much        length of needle is still inside the patient.    -   To remedy that shortcoming in the prior art, the inventor has        conceived of placing visible graduation marks, grooves or tiny        rings on the needle shaft, preferably extending near each end,        to accurately determine how much needle is still inside the        patient, and at the same time, determine and set the depth of        suturing.    -   d—Stops to prevent inadvertent needle exit: Another and perhaps        even more useful additional innovation is to place a structure        on the needle shaft at predetermined distances from the pointed        tip, like a ring, a bulb, an arrowhead, or some barbs that will        function as stops to prevent inadvertent exiting from the skin        and which also function as pivot points to indicate a change in        direction. These “stops” could be placed at fixed predetermined        locations on the needle shaft, with different needles for        different applications requiring different level of suturing.        Alternatively, the stops could be slidable or otherwise        adjustable such as by being mounted on ring sleeves so as to        adapt the same needle for use with different surgical        procedures. And, the stops could also be made to retract, fold        in, withdraw, or otherwise become reduced in cross section when        needed to thereby reduce the eventual exit opening or skin        puncture diameter, making it less traumatic to withdraw the        needle when it is time to do so. This “stop” innovation provides        a more objective indication to the surgeon as he works and which        helps him avoid unintended exiting, and thereby improves his        chances for a successful surgery, to both the patient and the        surgeon's benefit.    -   e—Needle construction comprising two or more parallel shafts        joined at the tip that are sharpened and made into cutting tips:        This innovative needle design comprises two or more parallel        shafts joined at the tips that are rendered pointy & sharp        cutting. The slit between the two shafts provides ample room for        the thread to move freely and yet be retained and potentially        wedged within the needle as it is used. Furthermore, the thread        loop knuckled at a 90° angle to the plane of the needle shafts        acts like a natural stop to prevent inadvertent needle exit and        the apex meeting point of the shafts also serves as a good        anchoring or retaining point for the thread. Of course, marked        graduations to gauge depth and full mechanical stops as        described above to prevent inadvertent exit are still useful        options.    -   f—Needle with an opening eye, or a slit allowing it to grab a        thread segment: In this construct, the eye of the needle can be        opened to insert a thread loop, or has a passage that allows a        thread segment of loop to enter the eye when the thread ends are        not available. Contrary to needles with a standard eye opening        that can only be fed the ends of suture threads through the eye,        this novel type of needle does not need to have the end of a        thread available to grab it. When the ends are buried or not        available it can grab a thread segment or loop through its eye        and continue to suture that thread. Such a needle makes it        possible to pass a loop back through the grommet either to close        a weave path or to emerge back through another grommet allowing        for a more complex and supportive weave. A double pointed needle        with the eye that opens is a very useful tool that can take a        suture loop and weave it deep through the tissues to complete a        complex stitch path. Two possible designs for the opening eye        needle invention are shown in FIG. 42. The embodiment shown in        the upper figure has a passageway providing a way to hook the        suture. The bottom figure depicts a deflectable or bendable arm        that can be deflected to allow passage of a suture therethrough        and into the eye, after which it closes to retain the suture.    -   g—Double pointed needles with two eyes. One that opens and the        other standard or that already has a swaged on suture or one        already with two threads, one close to each eye. In this even        more useful embodiment the needle has two potential suture        attachment sites, one close to each end. This can allow for        inserting even more complex weaves through even more complex        paths without necessarily having the thread ever grabbing dermal        fibers.    -   h—Needle where the cutting edge has small sharp dissecting        winglets that ensure an even level of travel as it courses        through the subdermal/dermal tissue planes. One such example is        depicted in FIG. 45.    -   i—Combinations/permutations that includes two or more of the        above design innovations:

In the RAFT surgical procedure described herein it becomes necessary toprovide an anchor with a tightening device in which a number of suturesare secured and used to adjustably lift and support the surgicallyrepaired/augmented breast. This could take the form of a simplesuspension hook introduced through a small slit and guided to curvearound the superior aspect of the clavicle to hook it to the patient'sclavicle. Alternatively, through a small incision on the anterior aspectof the clavicle a curved blunt needle can be introduced to curve aroundthe posterior aspect of the clavicle and emerge in the supraclavicularfossa, then without completely coming out (Shuttle principle) follow thepostero-superior surface of the clavicle and emerge through the anteriorwound. The thread that follows would have left a loop around theclavicle upon which the long threads can be suspended, looping down tothe upper abdomen and then locking the entire construct at a determinedlevel of tightness. This is the clavicle loop alternative that requiresa shorter double pointed shuttle needle with a tighter arc of curvature,as described in more detail in the Detailed Description.

In yet another alternative, the suspension can be done with the help ofa standard bone anchor of the type that has barbs that open once theouter cortex is pierced to prevent pull out. Or a bone anchor of thetype that is secured as a screw through the bone cortex may besuccessfully used. The anchor can be either introduced under directvision after making a small incision and dissecting the tissuesoverlying the clavicle, or preferably through a minimal incision using amodified drill guide tissue dissector or a cannulated screw insertedover a previously driven guide wire. (Such techniques are standard andwell known to skilled surgeons in the surgical art). The screw ispreferably a self-tapping screw to avoid the tapping stage required tocreate the threads in the bone.

Traditional anchors have threads and needles attached to them so thesutured tissues such as ligaments and tendons are secured to the bonethrough the anchor. In this application tissues are not sutured directlyto the bone, rather the anchor acts as a suspender for a loop that isbeing tightened into a purse string and brought cephalically. One simpleway is to have a strong suture loop or a hanging washer loop connectedto the anchor and then looping the long purse string suture through thatloop as it is being tied. However, this may be found to be cumbersomeand not ideal. Adjusting the tightness of the suspension and of thepurse string by tying a knot is not precise and the secured knot leavesbehind an undesirable mass of palpable bulky tissue. And, once secured,the process does not leave room for adjustment.

To that effect the inventor has conceived of various alternative designsfor simpler, more practical, adjustable, elegant and less bulky results.One such concept is the use of washers around the bone screw and byhaving the thread loop around these washer rings it can be locked inplace at the proper tension and level by tightening the screw.Furthermore there are many mechanisms by which threads can be securelylocked together at the desired tightness with a device where the threadsenter a passage or hole or loop and a screw or a cam mechanism tightensthis passage to lock them securely in place. This tightening device canbe an integral part of the anchor as a screw or a cam inside the alreadyscrewed in anchor, in which case a guide is required for the blindinsertion of the tightening device or screwdriver and a thread guidepasser loop is needed to pass the ends of the purse string suturethrough the deep anchor. In another embodiment, the tightening/lockingdevice can be a separate structure connected or attached to the anchorbut with more freedom of movement so that it can be exposed to pass thepurse string loops, tighten them and lock them in place and then thetightening/locking device can then be buried deep inside the tissuesonce the suspension is complete. Two embodiments are shown in FIGS. 43and 44.

There are a number of alternative means of locking the suture andsuspending it to the anchor. The requirements are that is should not bebulky so it is not visible or palpable and ideally it should beadjustable. Thus, alternatives such as ultrasound or heat welding thesutures together or locking them with a tightening clip or belt-likeband/washer system are also contemplated.

All of these alternatives are within the scope of this invention.

Another alternative is having the anchor already connected to the samelong suture that is connected to the needle and leaving a mechanismwhereby after driving its looped course around the breast the needle canpass through the anchor again or a ring on the anchor side of the threadto thereby complete its arcuate path. That ring could also have acrimping/screw/looping or cam locking mechanism that would allow lockingthe tightness of the loop and the suspension level.

The inventor has also conceived of a tissue mesher device which has beenfound to be extremely useful in several of the surgical proceduresdisclosed herein, especially in the RAFT breastaugmentation/reconstruction. For the breast surgery procedures describedinfra, pulling up the abdominal tissue to the chest is limited by theresultant tightness of the advanced tissues. The inventor has discoveredthat meshing the abdominal tissue can relieve the tightness therebyallow much more tissue to be advanced and recruited into the breastwhile maintaining a tolerable low tension to the tissues and thesuspension structure.

It is known in the art that making staggered small slits into a sheet oftissue allows it to expand. This principle is used by children to createornaments and in metallurgy to create metal meshes. This is also howplastic surgeons, using a device called a mesher, stretch small piecesof harvested skin graft and expand them to cover much larger wounddefects. However, with this invention, instead of meshing a skin graft,the surgeon meshes the tissues just under the skin that would otherwiserestrict the advancement of the abdominal apron. The tissue mesherpreferably consists of a number of sharp thin cylindrical rods withshort sharp cutting tips at their penetrating ends. The rods arepreferably firmly mounted in a staggered, orderly and predeterminedpattern on a handling device that can control the depth and angle ofpenetration and the degree of oscillation. Oscillatory and translationalsweeps of the mesher divide at different levels different anchoringfibers that hold the apron to the deeper abdominal wall. Due to theorientation of the rods, these alternating nicks do not open a tissueplane and prevent the formation of potential cavities which would beundesirable. Instead, as the individual fibers are cut by the rods atdifferent levels they slide past one another to create a complexexpanding inter-digitating scaffold. Thus without space generatingslicing cuts these combined nicks allow the abdominal apron to freelytranslocate cephalically and advance into the breast.

This process also creates a healing interface so that once healingoccurs, the apron scars down to its new location and tissue advancementis no longer dependent upon the sutures. Furthermore, this processcreates tiny interstices with loose vascularized tissue fibers, an idealenvironment with excellent graft to recipient interface where inaggregate, large volumes of micro tissue grafts can survive. Trauma,surgery, inflammation or radiation leads to tissue scarring, deficiencyand stiffness that can cause disfiguring body deformities, organdysfunction, motion restriction, pain or unstable non-healing wounds.The traditional treatment technique consists of surgically releasing thescar or the fibrous constriction by making cuts typically referred to asrelaxing incisions. This maneuver provides the tissue mobility necessaryto release the contracture, advance the freed up tissue to restoremobility or correct the contour defect or to reconstruct the tissuedeficiency. To address a more extensive scar and tissue deficiencyproblem, the classic surgical solution is to incise or excise the scar,free up the incision/excision edges and stretch them open to create awide gap, then fill the tissue deficiency void by transferring a blockof healthy tissue with its own blood supply in the form of a flap. Thisis a major surgical intervention and one that leaves behind a newdeficiency at the site where the flap was harvested. Unfortunately, thisstandard procedure of dividing the scar with relaxing incisions has manyshortcomings:

First, the large gap created when the released tissue is advanced leavesbehind a void or a cavity that needs to be filled in order to properlyheal. This void is usually filled with a flap of tissue; a step thatoften requires another major surgical intervention whereby vascularizedtissue taken from another location on the patient's body is transferredto fill that gap.

Second, the surgical incision itself to release the tissue leaves newpermanent scars. The same is true for the site where the flap isexcised. This amounts to treating a scar with a scar inducing procedure.

Third, this alternative does not address the stiff fibrous scar; it onlyincises it and divides it in half so that the bulk of the scar tissueremains in its present state.

Fourth, the degree of advancement that can be achieved with a singleincision is limited.

Fifth, by also dividing the endogenous blood vessels, the incisionimpairs the circulation and limits the amount of advancement.

Attempts at excising the scar are also often futile. The scar can beconceptually compared to a solid fibrous block of tissue, like a brickwall separating and tightly tethering two normal tissue compartmentsthat are more jelly-like in nature. Simply excising the block wall initself induces tissue trauma that often heals by leaving behind a newscar and often re-erects a new wall and does nothing to address the scartissue deficiency problem.

There is therefore a long felt need in the art for a better and lessinvasive alternative; a procedure that can truly address the fibrousscar, the tissue deficiency, the stiffness that limit organ function andjoint motion and the body contour defects caused by tetheringsurrounding tissues.

Fat grafting has been touted as a source of regenerative tissue, andcould, at the same time, address the scar and the tissue deficiency.Conceptually, a tight scar can be incised with a relaxing incision, itsedges mobilized apart to release the tightness and then regenerative fatgrafts inserted in the gap generated by the divided ends. A caveat isthat for the injected fat graft to survive it has to gain blood supplyfrom the recipient site. And as it is becoming well known in the artfrom the inventors experience and teaching that only droplets less than2-3 mm or so across can develop new blood supply to survive as grafts,grafts collected in pocket gaps larger than 2-3 mm across routinely diefrom an inability to restore circulation and thus necrose leaving behindcysts and more scar. This is why as the edges of a standard relaxingincision need to open up by much more than 2 mm to achieve the neededrelaxation, the larger tissue or flap inserted needs to be a block oftissue with its own blood supply in the form of a flap.

With the tissue mesher of the present invention, an inventive method foraddressing this issue consists of releasing the scar or the restrictivetissue in a mesh pattern with the tissue mesher invention to loosen itand allow it to expand into a fibro vascular scaffold that can accepttiny tissue grafts. The resultant construct transforms a rigid tightscar into a much larger soft piece of healthy normal tissue. This methodachieves a novel means of tissue engineering. Meshing the fibrouscontracture (or the normal but taut endogenous fascia) with this methodin effect generates a fibro-vascular scaffold that is conducive to thesurvival of large volumes of micrografts.

An important conceptual advance over the prior art, realized with thisinvention, is the observation that the human body can heal needle sticksin the 2 mm diameter range (like intravenous lines or venipuncturesites) with no significant scar. Therefore, while the needle tip isinnocuous in puncturing the skin, through an oscillatory or a to and frotranslational movement of the tissue mesher, it can be made to inflictsmall nicks in the deeper tissues in different planes.

Another important conceptual advance over the prior art is therealization that a needle (or rod) cutting tip will be much more likelyto cut a tissue placed under mechanical tension than mechanically loosertissue. To illustrate this, we can envision two violin strings wrappedaround each other. If we forcefully tighten one of the strings and keepthe other loose, a needle nick to this construct will cause the tightone to snap but will leave the loose one relatively unaffected. Thus,sharp pointed tips will preferentially cut the tight scar or the fibroustissue that is pathologically tight or placed under tension by theforced advancement while sparing the looser tissues such as nerves andblood vessels.

These two conceptual advances put together allowed the inventor todevelop the percutaneous tissue mesher invention and method as a meansof bringing about the tissue advancement alternative to the flap that isusually required in the prior art for plastic reconstructions.

There is a natural limit to how much tissue can normally be advanced inorder to close a wound defect, release a tight contracture or create abreast mound. This is due to the fibrous attachments between the skinand the deep immobile tissue layers such as the fascia underneath. Theserestrictive tissues can be collectively called the subcutaneousaponeurosis. Trying to advance the skin beyond the natural laxity limitof this subcutaneous aponeurosis places these structures under tensionrendering them much more susceptible to being nicked by a needle tip andthus separated than the surrounding tissues. Thus, without causingvisible skin scars, judicious percutaneous nicking of the subcutaneousaponeurosis can mesh expand the restrictive tissues/structures andfacilitate the tissue advancement required for a reconstruction thatwould have otherwise required a distant flap transfer.

This “needling” of the deep tissues that does not leave a skin scar isuseful in the release of Dupuytren contractures and other scarcontractures. The needling meshes the tight tissues that cause thecontracture and expansion of the meshed construct lengthens thecontracture to regenerate the tissue needed to relieve it.

Yet another conceptual advance is the realization that the meshingpattern can be designed and gauged to create small interstices that cantake advantage of the regenerative ability of tissues or become goodrecipient scaffold for fat grafts or other regenerative tissue grafts.The multitude of 2 mm or so gaps created by the meshing makes room for amultitude of tiny 2 mm or so graft droplets to survive. Fine meshingalso takes advantage of the natural regenerative ability of live tissue.This is pertinent as tiny gaps in the body tend to spontaneously fill inand regenerate tissue if the space and the proper milieu are maintained.(This is how when we cover a wound with a meshed skin graft, the gapseventually coalesce to from a new skin sheet that completely covers thewound). The small gaps might then fill up by themselves if kept open andprevented from collapsing again. Alternatively, these gaps can be filledwith substances with regenerative potential such as platelets richplasma, solutions containing growth factors, stem or other cells, oreven just fat. The gaps can also be filled with allograft preparationswhich in themselves have regenerative potential.

One of the means to keep the tissue under stretch after filling therecipient area with fluid (tumescence) is to apply a relatively stiffsplint, as previously described in a related patent application. This isalso another means of keeping the meshed space open and to invite thenatural regenerative abilities of the tissue to fill the thousands ofmicrocavities, which in aggregate would represent substantial volume oftissue gained naturally by using the endogenous abilities of the body toregenerate across tiny gaps. Thus a judiciously performed meshingfollowed by appropriate splinting might allow the generated construct tofill in with healthy regenerated tissue instead of scar tissue that willhave a tendency to subsequently contract and negate some of the benefitof the meshing.

It is also conceived that the meshing or expansion process does notnecessarily need cuts induced by a sharp instrument. Forced tumescenceby internal hydrostatic pressure can separate the native fibers toexpand tissues in a similar fashion. Therefore it is contemplated thattumescence, as an adjunct or alone, can also be used to expand thetissue and generate an extracellular scaffold matrix with a multitude oftiny gaps. This matrix could then be induced to regenerate the tiny gapson its own or with the help of added regenerative agents such asautografts, stem cells, allografts or otherwise.

The inventor has found that the length of the nicks and their spacingwill determine the amount of expansion that can be achieved. Tooaggressive a meshing will destroy the circulation, leading to ischemiaand necrosis. It can also tear the deeper tissues and result in thecreation of excessively large cavities instead of those of a delicatefibrovascular recipient scaffold. Excessive meshing destroys theintegrity of the scaffold and leads to excessive numbers or sizes ofcavities. Too many or too large cavities are to be avoided becausetissue grafts lodged inside a cavity are far from the capillaries of therecipient tissue and will die from failure to re-vascularize. Thereforethe inventor realizes that since the meshing ratio is limited, it is theamount of tissue that is meshed that determines the amount of tissuegain. In practical terms, from experience the inventor has found that ameshing ratio preferably up to about 20% achieves the desired resultswhile more than about 30% will usually lead to undesirably wide gaps andcavities in which fat grafts will die. Using the 20-30% ratio, thismeans that to gain 2-3 cm of tissue, an area about 10 cm long will needto be meshed.

The mainstay of tissue engineering consists of seeding scaffolds withcells. The current practical limitation of tissue engineering is not thecells, as these are readily available from simple liposuction or fromtissue cultures, but the three dimensional supporting scaffold withfunctional blood capillaries connected to the circulation of therecipient. This is why to the best of the inventor's knowledge currentlyavailable tissue engineered products are limited to a few cell thickalloplastic constructs that can survive by diffusion such as dermis orcornea. It is the inability in the prior art to build a fibrovascularscaffold (fibrous scaffold with capillary circulation) in the laboratoryand connect it to the recipient blood circulation that limits theability to build three dimensional solid organs or blocks of tissue.

This invention and method, however, is akin to tissue engineering. Itcreates in situ a fibro vascular scaffold out of a restrictiveaponeurosis or a block of scar tissue and it seeds this vascularconstruct with healthy cell grafts. As the droplets of fat (or otherregenerative seeded cells or reagents) engraft and mature in this newscaffold, the effective result is the generation of new fibro-fattytissue. The inventor calls this novel procedure PALF for PercutaneousAponeurotomy & Lipo-Filling. This is the inventor's novel andnon-obvious regenerative alternative to the classic FLAP tissuetransfer. In his investigations, the inventor has successfully performeda PALF procedure to patients that would have otherwise required a FLAPprocedure to achieve the necessary plastic reconstruction and theresults are successful.

The tissue mesher used in this procedure preferably consists of an arrayof needles that are fixed on a flat or slightly curved platform and thatcan penetrate the skin at various predetermined depths and may beoscillated or translated laterally to nick the deeper aponeurosis undertension. In various embodiments, the needles may be permanent sharppoints or replaceable cartridges consisting of an array of sharp points,or commercially available hypodermic needles that can be loaded andtightened into the device at varying depths or with varying lengthneedles or rods. The needles are preferably arranged on a supportingdevice in a staggered fashion and may preferably be organized either inone or more longitudinal rows or even more preferably in a singular,triangular, quadrangular, hexagonal, more rounded fashion depending uponthe specific application and requirements. Three Al blocks, screwedtogether, with 3-19 holes, clamping hypodermic needles at varying depthsranging from ½ cm to 3 cm, alternating a cm apart, may be preferablyused. If only a two dimensional PALF is desired, then all needles/rodscan be the same level, but if three dimensional it would be preferred todo multiple levels. The hexagon pattern is preferred, but others work aswell, depending on patient anatomy.

The edges of the device, or the entire plane upon which the device pinsare mounted may also be rounded or partially spherical to facilitate therocking or oscillatory motion needed to nick the underlying tissues.

The tissue mesher may also be either fixed and cause the deep tissuenick with a translational motion of the skin surface. Or it can bedesigned such that when placed against the skin, a hinge mechanismallows the needles to oscillate around one or more axes or a ball likejoint or equivalent. The sharp cutting tips can either be constructedout of solid shafts with sharp pointed and cutting tips or alternativelyhollow hypodermic needles. If hypodermic needles are used to deliver thegraft in a controlled fashion, they may be connected to a pump/syringesystem. The hypodermic embodiment connected to a pump/syringe system isconsidered by the inventor to be ideally suited to deliver the graft ina controlled, diffuse and evenly distributed fashion throughout thetopography of the recipient.

Stops may be provided to indicate a penetration at pre-determineddepths. Or the tissue mesher may have an adjustable stop platform thatdetermines the level of penetration.

One embodiment for the tissue mesher, labeled as a Rigottome™ mesher, ispreferably a surgical instrument with a number of thin cylindrical rodsthat have short cutting tips at their apex. It may be introducedpercutaneously (through the skin) to create a specific alternatingpattern of multiple small cuts throughout the deep subcutaneous tissues,in accordance with the method described herein. Depending upon thespecific technique used, the Rigottome™ mesher can generate a two orthree-dimensional mesh of potential spaces inside a sheet or a block oftissue. When placed under tension the meshed tissue expands in one ortwo dimensions to open up these potential spaces into tiny cavities.Mesh expansion generates a beehive type of construct for the 3D mesh ora wire mesh construct of the 2D mesh. The tension could be an externallyapplied mechanical force or an internally induced tumescence such as canbe achieved by injecting a fluid. That fluid may include normalphysiologic solutions, regenerative reagents, or a suspension of cellsor tissue grafts that can fill the tiny created cavities to successfullyengraft. Other materials that can be added include processed allograftsable to regenerate tissue after being inserted inside the matrix.Depending upon the technique, the process allows the 2D linear expansionof a sheet of tissue where the interstices can be filled with fluid orgraft, or a 3D volumetric expansion of a block of tissue into a largerblock with the multiple tiny generated cavities filled with largeramounts of fluid or graft. This process transforms a solid sheet (2Dexpansion) or a solid block of tissue (3D expansion) into a recipientscaffold consisting of a multitude of tiny cavities into which verylarge graft volumes can still maintain the critical 2 mm graft torecipient interface required for revascularization and survival. A solidblock turned into a looser and larger framework with large numbers ofstaggered interstices where the injected graft can survive.

As a result of transforming a solid block or a sheet into a recipientstructure, large volumes of fluid or graft can be infused inside thattissue with the expectation that the graft will survive. The methodtransforms a solid block into a loose graft recipient scaffold, or arestrictive cicatrix into a regenerative matrix. The tight fibrouscicatrix becomes larger, and by becoming filled with healthy fat graft,or by healthy new regenerated tissue, it becomes more like thesurrounding tissue. Depending upon the density of the scar, one or moresessions can make the scar totally disappear.

The general application of this novel principle is not believed by theinventor to be limited to scar tissue. The inventor considerers that anyblock of tissue, whether an internal organ such as liver or kidney orwhether muscle or fatty or normal can be meshed and expanded to createtiny gaps that the body can regenerate either naturally if the gaps aresmall enough and maintained open or with the help of instilled reagentssuch as the ones mentioned above.

To mobilize the abdominal panniculus and allow it to advancecephalically we not only need to expand as described above, but we alsoneed to free it from its anchoring fibers to the deep attachments.Realizing that the apron has already been mobilized to a certain extentby the crisscrossing tunnels of the liposuction cannula, what stillprevents advancement are the residual anchoring fibers that the normalcannula does not cut. What is necessary at this stage then is to dividethese fibers and for mesh advance the fascia that is anchoring theirorigin.

Yet another invention conceived of by the inventor is a tissuedissector. The meshing of the deep anchoring fascia is performed withthe tissue mesher described above. But the inventor has discovered thatwhile meshing provides some advancement it is sometimes not enough andmore is needed. To that effect a device is needed that will snare andavulse and cut these vertical fibers which anchor and restrain thetissue from significant relative movement. The inventor has found thatsuch a device designed to hook and avulse perforators and verticalfibers that prevent vertical swelling when tissues have beenhorizontally stretched but vertically restrained (such as what happensto tissues overlying long standing breast implants or tissue expanders)is needed. One embodiment for such a device is a thin long metal rodthat could be solid or hollow, to simultaneously allow aspiration orinjection. Its external surface is preferably rough like a rasp withsharp points or ridges or, if necessary, the inventor envisions that itcould be more aggressive and have hook like or shark fin like wingletextensions for snaring the vertical perforator fibers. These wingletsare preferably arranged radially around the shaft or in one side orplane of the shaft depending upon the specific dissection needed. Thetip of the device is preferably round or flat round spatulated, butpreferably not pointed or sharp so as to remain in the subcutaneousplane and not puncture the skin superficially nor the deeper muscletissue and viscera. The device is preferably thin enough to beintroduced through a needle puncture in a concealed corner of the tissuethat needs to be dissected and elevated. Thickness preferably variesfrom 1.0 to 3.5 mm. The inventor contemplates that thinner rods will nothave enough mechanical torsional strength to do most jobs and thickerones will leave more noticeable scars at the entrance points. The devicepreferably has four portions: a short smooth round or spatulated tipthat can tunnel through the tissues while maintaining the device in theselected plane; This part can vary in length from 0 to 1 cm. An activeportion (the length with ridges or teeth or dissecting hooks/fins); thispart can vary in length from 1 cm to 30 cm, depending upon theapplication. An inactive smooth proximal portion without roughening thatwill not damage the entrance site during the to and fro, oscillatory orother movements required to release the tissues; and an ergonomicallyfit handle portion, though a strong clamp gripping player couldsubstitute for that portion. Depending upon the patient's anatomy andthe task required, the active portion could be from about 2-3 cm toabout 20-25 cm long.

A related invention conceived of by the inventor is a subcutaneoustissue rasp and dissector. There are a number of conditions where thetissues are lax and where tissue tightening is necessary and beneficial.This includes pathologic conditions where ligaments, tendons, fascia andmany other deep structures stretch out or become attenuated. Tighteningof the skin is also the mainstay of plastic surgery. Facial wrinkles areironed out and the lax skin is tightened in the common faceliftrejuvenation procedures. Tissue tightening is also required to lift backup what gravity has stretched out over the years. Examples includefacial jowls, ptosis of the breasts and overhanging abdominalpanniculus.

Tightening the tissues currently requires a surgical intervention todissect the lax tissue, redrape or re-tighten it to the desired positionand resect the excess lax tissue and/or suture plicate the laxity. It isalso well known that post inflammatory healing deposits scar tissue thathas an inherent tendency to contract. Therefore, to bypass theinvasiveness of surgery, a number of devices in dermatology and plasticsurgery have been designed to achieve and deliver a controlled deepdermal/subcutaneous tissue injury that leads to inflammation andsubsequent healing with scarring and fibrosis that cause the desiredretraction and tissue tightening. Most of the devices as known by theinventor deliver the active agent in the form of laser light, focusedultrasonic energy, radio-frequency energy, or thermal energy. Theyinclude many complex design features to ensure that the superficialtissues are protected while it is only the deeper ones that will absorbthe energy and will be affected. (What is sought to be avoided is thedelivery of the injurious energy to the epidermis and most superficialdermal layers which will cause blistering and subsequent visibleunsightly scars). These devices were mostly designed to treat thewrinkles of the aging face. Unfortunately, these devices have limitedeffectiveness; proof is that despite years on the market, they have notreplaced the surgical facelift operation.

The effectiveness of these devices is limited by their inability tosafely deliver the amount of injury to the deep dermis and subcutaneoustissue that will result in the required scar retraction while completelysparing the more superficial delicate tissues from the injurious agent.Since the distance between these two tissue layers is of the order ofmillimeters and fractions of millimeters, even a limited scatter of themost precisely focused agent is bound to cause collateral damage. Thisis particularly obvious since the injurious agent is delivered from theoutside surface and therefore has to travel through the delicatesuperficial structures without injuring them before reaching the layerthat need to be treated.

As an alternative to these prior art devices, the inventor has developeda subcutaneous tissue file or rasp that can directly mechanically abradedeep tissues and in a precise and controlled fashion to cause scarringto the abraded tissues without affecting the more superficial tissuesabove as well as the more delicate external surface of the skin. Thisinvention allows the surgeon to manually deliver in a controlled fashiona mechanical abrasive injury exactly where it is needed to the innerinternal surface of the skin, causing it to scar down and contract asdesired to achieve the tightening and lifting of the treated tissues. Tobe most effective, this abrasive injury is delivered to tissues thathave already been loosened and partially separated and mobilized fromtheir anchoring deeper structures, a step that can be achieved by thetissue dissector described herein. The inventor realizes that thestructures to be tightened need to be first dissected and mobilized freewith the tissue dissector and then allowed to redrape and made tocontract with the tissue abrader. The percutaneous tissue dissector andthe percutaneous tissue abrader are related devices consisting of a thinlong relatively stiff rod of medical grade material which differ by thedesign and aggressiveness of the teeth or ridges built along theirfunctional part in a continuum going from the least abrasive tissue filewith ridges, to the tissue rasp with needle like teeth to the mostaggressive tissue dissector with barbs or fins that act as a saw. Animportant feature of these devices is their overall external diameterthat is thin enough so that they can be introduced through needlepunctures in the 2-3 mm range. Puncture sites that require no sutures todose and essentially leave no scar. Thus while the central rod islimited in OD, the barbs or fins could be retractable with a mechanismthat pushes them out once the file is introduced through the narrowerpuncture site.

Furthermore, to be most effective in and to obtain the best retraction,the abraded tissue should be redraped over the deeper structures andkept loose under no tension till the healing process that takes a fewweeks causes it to retract and scar down in the new position. This canbe achieved in two means or a combination of these two.

-   -   1—Applying an external adhesive supporting structure such as a        thin adhesive supportive bra in the case of the breast or an        adhesive supportive, repositioning mask in the case of the face.        This post procedure bra or holding and molding device preferably        can stay in place for the required few weeks, or is easily        replaceable till the tissues scar down.    -   2—Inserting supportive sutures that stay deep and serve to        reshape, plicate, contract or suspend the deep tissues. These        sutures are best inserted with the double ended needles and the        grommets described herein and as needed suspended with the        anchor and tightening devices also described above.

In a preferred embodiment, the device preferably consists of a thinsolid metal probe (or a hollow cannula that can also deliver fluids ortissue and cell suspensions if needed) that can be inserted through afew puncture sites or tiny hidden incisions and then be tunneled underthe skin to where the tightening or dissection is desired. The rodpreferably has a blunt, round hemispheric tip to prevent it frominadvertently puncturing tissue planes or a round spatulated tip todissect the tissue planes without puncturing through them. Some of thefins or barbs can be designed such that they are retractable by a screwor an internal push mechanism. The mechanical abrasion can be manuallyperformed, or alternatively the filing motion can be delivered by anexternal mechanical source that either pistons back and forth, in andout, and/or rotate or oscillate. This internal skin file device iscompletely different from other prior art file and rasp devices in thatit is a thin rod of medical grade material that has relatively sharpfine ridges along its active portion and may have an inactive portion,if desired.

It is also understood that to perform such a dissection, the tissuesoften need to be primed with a tumescent infusion that can help open upthe tissue planes, put the restrictive fibers under tension and thusmore prone to avulsion, and cause vasoconstriction that will preventbleeding from the avulsed vessels. External traction could also providean alternative/supplement to the tumescent infusion.

Yet another related invention addresses the problem of breast ptosis.Breast ptosis, is the drooping of the breast from acquired laxity of thesupporting ligaments and the skin envelope of the breast. It is the mostcommon deformity of the female breast and virtually all women willdevelop some breast ptosis with age. It is estimated that over 100,000surgeries alone are performed in the USA to correct this deformity.Ptosis is classified according to the relationship between the nippleand the inframammary fold. In the non-ptotic breast the nipple is abovethe level of the fold. In grade one ptosis, the nipple is at the levelof the fold; grade two, the nipple is below the fold; and grade three,the nipple is the lowermost structure of the breast.

While minor degrees of ptosis, can be corrected by filling up thestretched out skin envelope with an implant, larger degrees of ptosisrequire re-tailoring of the skin envelope to bring the nipple back toabove the level of the inframammary fold and to restore the hammock-likesupporting effect of the lower pole breast skin. This tailoringoperation requires multiple incisions to remove (or plicate) the excessskin and therefore leaves behind unsightly scars. These incisions andscars are believed to be the reason why the overwhelming majority ofthese deformities are never sought to be corrected. Therefore a deviceand method that could be used to surgically correct breast ptosiswithout incisions or scars would be a very useful.

Women with ptotic breasts typically wear a support brassiere for most oftheir waking hours for at least cosmetic reasons. Some stick-onbrassieres have recently been developed where, as the adhesive tapeplicates and folds in the excess skin, a normal breast contour isrestored.

The main problem in breast ptosis is the excess skin and laxity of theInternal suspensory ligament (also called ligament of Cooper). Excessskin in the vertical dimension along with vertical elongation ofCooper's ligament causes a loss of the suspensory effect and brings thenipple down. Excess skin in the transverse dimension along with laxityof Cooper's ligament causes a loss of the hammock-like support of thebreast permitting it to fall further. Therefore the skin and theligaments need to be tightened in two dimensions in order to restoreboth the suspension and the hammock. To remedy this issue, the inventorhas conceived of a kit and a method of surgically inserting a permanent,preferably woven, brassiere under the breast dermis to restore thesupporting ligaments, to reconstruct a hammock, and to induce the skinto shrink.

The kit device preferably includes:

-   -   1—A bone anchor, in order to secure the breast to a solid fixed        anatomical structure. That anchor is preferably inserted in the        sternum, the ribs or the clavicle. The threads weaved into the        breast as explained below connect to this anchor.    -   2—Threads, that are surgically tunneled subcutaneously and        weaved inside the breast to restore the ligaments and the        hammock. These threads could be made of suture materials        commonly used in surgery or preferably out of synthetic,        allogenic or alloplastic materials that favor their ultimate        transformation into fibrous ligament. Preferably, the threads        are also color coded such that each thread has a different color        to facilitate the recognition of the ends of each thread as they        are tightened during the surgery. The inventor has found that a        typical procedure would preferably be expected to require 6-12        threads of different length.    -   3—Special needles, to drive these threads. The needle is        preferably curved, double pointed with graduation marks near the        pointed tip that indicate the level of penetration, and with the        thread swaged in the middle or close to one of the sharp points.        Another type of needle that may instead be used is one where the        eye can be opened to allow the insertion of a loop. Yet another        needle is one that includes a stop to prevent inadvertent exit        as it is shuttled through the tissues. These needles may be the        same needles as described above.    -   4—A brassiere, that can be applied sterile on the operative        field as a surgical aid. This brassiere is considered by the        inventor as an important element of this invention. After        restoring the normal anatomical relationships of the breast        architecture like a well-fitting brassiere would, the brassiere        desirably becomes adhesive and sticks to the skin and becomes        relatively plastic or rubber-like hard. The brassiere is        preferably transparent or translucent in order to allow        monitoring of the status of the underlying skin and to insure        that the brassiere is still adherent. The brassiere also        preferably has marked on its surface the preferred pattern of        weave that the threads should follow, to thereby guide the        surgeon during the operation. The external temporary brassiere        provides static support for the breast while the weave is        surgically formed so that the individual threads are passively        weaved and their loops locked at the appropriate length without        being under tension in the process.    -   5—An important attribute of this brassiere is its ability to        hold the breast in the desired shape and suspend it in the        desired position. It is also preferably rigid and well adherent        to the skin such that snugly pulling the threads that constitute        the weave locks them all at the ideal length and tightness for        an even contour. If the brassiere is not adherent or not stiff,        some threads might be tightened more than others to cause        unsightly dimples. In essence therefore it is this brassiere        that primarily determines the length and tension on the        individual threads of the construct to make it even.    -   6—Preferably needle sleeve grommets, that fit around the needle        as it emerges out of the skin and become the guide for the        needle when it is reinserted again into the skin. These grommets        keep the threads and the weave in the deep tissue planes as the        needles come in and out of the skin, preventing the suture loop        from catching dermal fibers as they perform the weave. This        needle sleeve grommet is also considered by the inventor as an        important and innovative part of the invention. Without these        grommets, a shuttle needle (a double pointed needle with the eye        in the middle) has been found by the inventor to only perform a        simple circum-mammary loop. With the grommet keeping the        skin/subcutaneous tunnel open, a loop of the read can stay        outside and then interlocked with another loop coming out of the        same tunnel so that the interlocking weave pattern can be        performed and brought back down inside the deeper planes where        it does not result in visible skin dimples.    -   7—Preferably a crimpling/locking device, that adjusts the length        of each of the individual supporting threads as a function of        its path along the stretched out skin envelope. This crimpling        or locking device eliminates the need for the standard tying of        knots. This prevents leaving behind a suture knot bulk and makes        it easy to appropriately adjust the length and tension of the        threads. The final exact adjusted length of each individual        thread weaved through the breast has been found by the inventor        to be important to the success of this procedure. The multiple        threads preferably function together to distribute the support        evenly among themselves in order to prevent dimples and contour        irregularities.    -   8—Optionally, special dissector cannulas and liposuction and        lipografting cannulas, if desired.

With this kit device and the method of application described herein, aninternal brassiere can be surgically constructed subcutaneously tosupport the breast and lift it up to restore its normal aesthetics. Mostimportantly, the procedure leaves minimal scars as there are essentiallyno incisions and no sutures marks, only needle size puncture holes whichheal leaving virtually no scarring.

An alternative to this inserted weave pattern is an external supportiveshaping brassiere that firmly adheres to the skin after the dissectionwith the rasp is performed and can be worn for the long period of timenecessary for the tissues to heal in the new location and for thedissected skin to retract to the new envelope shape imposed by thebrassiere.

The inventor also has conceived a similar device and method to re-drapethe stretched skin and jowls of the aging face. Double needles such asthe ones described above can be used to insert a pattern of deep suturethat can tighten or suspend the tissues. A supportive mask or bonnet isalso included that can supplant/replace the sutures once thepercutaneous dissection of the skin and its stimulation to retract areinduced with the rasp and the file.

While many of the advantages and features are briefly described above, amore thorough understanding of the invention(s) may be gained byreferring to the drawings and the Detailed Description of the PreferredEmbodiments which follow.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a side view of a grommet invention, inserted through apatient's skin, and detailing a flange and retainer;

FIG. 2 is a side view of a grommet invention, inserted through apatient's skin, and detailing thread tie off structures;

FIG. 3 is a side view of a grommet invention, inserted through apatient's skin, and detailing a flange with securing structure;

FIG. 4 is a perspective view of a jig extending between two adjacentgrommets to guide a needle from one grommet to the other;

FIG. 5 is a side view of a double pointed needle of the presentinvention, with an eyelet at one end thereof;

FIG. 6 is a partial view of several variations of the needle invention,with cross sectional views detailing their different embodiments;

FIG. 7 is a perspective view of a double shaft needle embodiment withdouble pointed ends, with cross sectional views detailing differentpossible shaft shapes possible for use;

FIG. 8 is a top view of a double shaft needle with a central threadshuttle;

FIG. 9 is a side view of a double pointed needle with centralreinforcement and graduations marked on an end;

FIG. 10 is a side view of a double pointed needle with reinforcementdepicted at an eyelet, whether positioned in the middle or at an end ofthe needle;

FIG. 11 is a partial view of a needle end inserted through the skin witha stop to prevent inadvertent exiting of the needle during the surgicalprocedure;

FIG. 12 is a partial view of a needle end inserted through the skin witha different design stop;

FIG. 13 is a perspective view of a needle end with a retainer threadedonto the needle to provide an adjustable retainer;

FIG. 14 is a partial perspective view of a needle end with a threadedretainer comprising retractable umbrellas;

FIG. 15 is a partial perspective view of a needle end with a slidableretainer comprising retractable umbrellas;

FIG. 16 is a partial perspective view of a needle end with an arrowheadstop and depicting alternate eyelets for the thread;

FIG. 17 is a perspective view of a “J” shaped needle as used in a RAFTbreast augmentation/reconstruction procedure, with thread swaged ontoone end thereof;

FIG. 18 is a side view of two alternative stops for use with a “J”shaped needle;

FIG. 19 is a partial cutaway view of a bone anchor detailing the suturesgathered through a ring with the anchor secured to the clavicle;

FIG. 19 (a) is a perspective view detailing the bone anchor and variousalternative embodiments thereof;

FIG. 20 is a partial view of an end of a tissue dissector and rasp;

FIG. 20 (a) is a partial view of the working ends of various tissuedissector and rasp alternate embodiments;

FIG. 21 is a perspective view of a first embodiment of a tissue mesherinvention comprised of three rectangular solids screwed together withneedles extending through a matrix of eight holes;

FIG. 22 is a plan view of a second embodiment of the tissue mesher witha matrix of nineteen holes;

FIG. 23 is a perspective view of a third embodiment of the tissue mesherarranged in a sliding framework to provide lateral translation of theneedles;

FIG. 24 is a partial view of several articulated joints to permitlateral translation of a tissue mesher or grommet jig;

FIG. 25 is a partial view of several articulated joints to permitlateral translation of a tissue mesher or grommet jig;

FIG. 26 is a partial view of yet another articulated joint to permitlateral translation of a tissue mesher or grommet jig;

FIG. 27 is a side view of a rack and pinion drive for a tissue mesher toprovide lateral translation of the needles;

FIG. 28 is a plan and side view of a tissue mesher with yet anothermatrix of needles;

FIG. 29 (a)-(g) are frontal views of a patient detailing the method ofperforming a RAFT breast augmentation/reconstruction;

FIG. 30 is a side view of a normal breast, detailing the verticalconnecting tissue otherwise restricting abnormal cephalic movement ofthe upper abdominal tissue;

FIG. 31 is a side view detailing the cephalic sliding permitted as thevertical connecting tissues are “nicked” by a tissue mesher to break;

FIG. 32 is a side view detailing how the abdominal tissues mushroom asthe RAFT procedure completes, with the vertical connecting tissuereleased;

FIG. 33 (a)-(c) are side, cross sectional views detailing the method ofperforming a breast lift using the tissue dissector and tissue raspinventions;

FIG. 34 is a cross sectional view of the breast with the bra supportingit, a pair of grommets inserted over the needle and through the bra withthread passing through one of the grommets;

FIG. 35 is a cross sectional view of the breast and bra, with a grommethaving a shoulder to hold it in place in the bra and a pair of threadslooped together to start the weave;

FIG. 36 is a perspective view of the basket weave result achievedthrough use of the invention, the basket weave being woven in placesubcutaneously in the breast;

FIG. 37 is a perspective view, with the breast in phantom, depicting thebasket weave in relation to the breast as it is formed inside thebreast;

FIG. 38 is a side view of the shuttle needle, with graduation marks neareach end and a thread through a centrally located eye;

FIG. 39 is a cross sectional view of the breast with bra, and the needleinserted through one of the grommets and into the breast with a threadbeing threaded through the breast;

FIG. 40 is a cross sectional view of the shuttle needle inserted throughgrommets at each end and showing the thread looped through one of thegrommets;

FIG. 41 depicts in several views the use of the Rigotome;

FIG. 42 depicts the needle with opening eye;

FIG. 43 depicts a clavicle suture fastening, double ring embodiment:

FIG. 44 depicts a clavicle suture fastening, fixture embodiment; and

FIG. 45 depicts a needle embodiment with ailerons or wing extensions.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

As shown in FIG. 1-3, a grommet 20 includes a central, cylindrical shaft22 preferably with a top hat, annular flange 24 for engaging the skinsurface as it is inserted into an incision in the patient's skin. Thecylindrical shaft 22 preferably has a beveled tip 26 to aid in itsinsertion and which provides directionality for locating and threadingtherethrough a needle and thread, as is explained in greater detailbelow. Various embodiments of a stop 28 are depicted, as follows. Asshown in FIG. 1, a collapsible pair of wings 30 may extend from thesidewall of the shaft 22, and which open to block unintended removal orexiting of the grommet 20 during use but which may be collapsed tofacilitate its removal, when desired. Two other embodiments of a stop 28are depicted in FIG. 4 and include a collapsible umbrella 32 extendingfrom the flange 24. Or, as yet another alternative, the flange 24 may beprovided with a series of holes 34 through which a suture, pin or otherstructure 36 may be inserted either parallel or oblique to the shaft 22to secure the grommet in place. As depicted in FIG. 2, a threaded loopor suture securing or retaining structure comprising a cleat 38 aroundwhich the thread (not shown) may be wrapped much like a marine gradecleat. Alternatively, a spiral hook 40 may be provided through which thethread (not shown) may passed and wrapped around to the same effect.Thus, with the grommet 20, a designated opening, or incision, isreliably located and which is “clear” of surrounding tissues which mightotherwise be undesirably caught or snagged as the needle and thread ispassed therethrough.

As shown in FIG. 4, a grommet jig 42 may be secured to two adjacentgrommets 20 to guide a needle 44 and attached thread 46 from one grommet20 to the next grommet 20 during the RAFT procedure as described herein,or for any other surgical procedure requiring a suture to be implantedbetween adjacent grommets 20 or incisions. The grommet jig 42 generallycomprises an articulating or swivel mounted fixture 48 at each grommetlocation and a fixed bar 50 extending therebetween. There are variousstructures and construction details indicated and shown in FIG. 4, thedetails of which would be apparent to those of skill in the art.

As shown in FIG. 5-18, a number of embodiments with alternative noveland unique features of surgical needles are depicted for use not only inthe RAFT and PALF procedures but also for general surgical use. Theseare typically made of surgical stainless steel for reliablesterilization and as would be known in the art. Several of them havecutting edges and points in various configurations although others, asknown in the art could be used as well. At least one needle is speciallyconfigured for the RAFT procedure and its specific use will beexplained.

Referring now to FIG. 5, a generally curvilinear, double pointed needle52 has an eye or eyelet 54 located near an end 56 through which threadmay be passed when used, or which may have thread swaged thereat for asingle use needle 52. FIG. 6 depicts various alternative cutting pointswhich may be used as desired or as indicated for a particular procedure.As shown, a round point 58 has a circular cross section and which isespecially suited for creating a smooth entry hole. A cutting point 60with a long bevel 62 provides a trilateral cutting edge 64 for openingup a wider incision. A knife or blade tip 66 provides a bilateralcutting edge 68 which will cut through the tissues more evenly andassists the surgeon in dissecting the tissue planes, and maintaining therelative position of the needle with respect to the tissue planes.Staying level and staying in the same plane is helpful in avoiding thegathering of tissues, similar to drawing a curtain together, whilepreforming the “purse string” RAFT procedure as described herein. FIG. 7depicts a particular construction of a curved needle 69 as has been usedby the inventor. As shown, a pair of shafts 70 are joined at their ends72, such as by swaging them together, leaving a longitudinal gap 74therebetween and through which a thread 76 may be inserted. The ends 72are sharpened into points as shown. The shafts 70 may have differentcross sections, such as being a simple rectangle 78, semi-circle 80, orcircle 82 and be suitably used for this construction along with manyother shapes. With this construction, the thread 76 may be left free toslide along the length of the needle 69 as it is used, or it may beswaged or otherwise attached anywhere along its length, as desired. FIG.8 depicts a straight, double pointed needle 84 formed from a joined pairof shafts 86, as before. However, additionally, a centrally locatedpassageway 88 is formed between the shafts 86 and a shuttle 90 with anattached thread 92 is positioned within the passageway 88 so that it mayfreely slide from end of the needle 84 to the other as it is used.Alternately, the shuttle 90 and passageway may be provided and becrimped into place by the surgeon to suit his individual preferencedepending on his technique, the surgical procedure, or the particularpatient. This same construction could also be incorporated into otherneedle designs. FIGS. 9 & 10 depict alternative structures forreinforcing that part of the needle through which the eye is located, toavoid inadvertent breakage of the needle as it is being used. In FIG. 9,the needle 94 is a double pointed, curvilinear needle with a centrallylocated eyelet 96. The reinforcement is provided by providing a swagedsleeve 98 of material near the mid-point where the eyelet 96 is drilledor otherwise formed into the needle 94. Also, as shown in FIG. 9, aseries of measured graduations 100 are provided at each end 102 whichindicate to the surgeon the position of the needle 94 as it is partiallyinserted in the patient so that inadvertent exiting of the needle 94 isavoided, and for more precise placement of the suture during theprocedure. In FIG. 10, a curved, double pointed needle 104 has athickened shaft 106, which could also be a sleeve swaged into place,surrounding the eyelet 108 as positioned either at an end 110 or at amid-point 112.

The needle embodiments of the present invention may also be providedwith one or more of a series of alternative design stops, as depicted inFIG. 11-17. In FIG. 11, an end 114 of a needle 116 is depicted with anarrowhead shaped stop 118. The stop could be either threaded onto theend 114 of the needle 116 so that its position could be adjusted by thesurgeon, or swaged into a fixed position. The stop 118 could also beprovided in different lengths. A suture 120 may also be swaged into thestop 118. In FIG. 12, a stop 118 shaped like a ball 122 may also beprovided, again either with internal threads to permit adjustment by thesurgeon or swaged into a fixed position. In FIG. 13, a stop 118comprises a fin 124, one or more of which extends radially from theneedle end 126. The fins 124 may be provided as part of a sleeve 128that could be threaded onto the needle end 126, or swaged directly ontothe needle end 126. FIGS. 14 & 15 depict another stop 118 comprised ofone or more retractable barbs 130 which may be either threaded onto theneedle end 132 (FIG. 14) or swaged into fixed position onto the needleend 132 (FIG. 15). The barbs are swivel mounted so that a retainer 134may be slid down the needle end 132 to hold them in a retracted positionfor removal of the needled end 132 at the completion of the surgicalprocedure. FIGS. 16 & 17 depict other stops 118 comprised of anarrowhead shape, or fish hook, or cone, or barb 136, with alternatelocations of the eyelet 138 (FIG. 16) for attaching the suture. Inessence, the stop designs shown are exemplary, the function of the stopbeing to give the surgeon a physical indication of the needle positionduring the course of the surgery by mechanically restricting exiting ofthe needle end from the patient.

A specially shaped needle 140 is depicted in FIG. 18, especiallyintended for use in a RAFT surgical procedure. It comprises essentiallya “J” shape of a longer relatively straight portion 142 transitioninginto a more sharply curved portion 144 with pointed cutting end 146. Thecurved portion is preferably a beveled, cutting shape, such as atrilateral cross sectional shape 148, to facilitate its being driveninto the deep tissues of the patient's chest. The beveled cutting shapemay extend further into the straight portion, depending on theparticular technique, patient anatomy, or surgeon preference. A suture150 may be either passed through an eyelet 152 at the opposite end 154,or swaged into fixed location thereat. Its use in a RAFT procedure isexplained in greater detail, below.

As depicted in FIG. 19, a bone anchor 156 may be screwed into orotherwise attached to a patient's clavicle in a RAFT or other breastaugmentation/reconstruction procedure for gathering the one or moresutures passing in and around the breast and securing them after thereconstituted breast is desirably positioned. The bone anchor mayinclude a ring or washer 158 for receiving the suture(s) 120 and whichallows them to be individually adjusted in length before being affixed.

FIG. 19 (a) depicts various alternative embodiments for the bone anchor156 including different arrangements for attaching the suture 120. Asshown therein, in a first embodiment the bone anchor preferablycomprises an orthopedic, Phillips head screw 300 which is preferablycountersunk into the clavicle so as to be flush with the surface of theclavicle. A preferably thin, flexible but resilient washer 302 ispreferably attached to the screw 300, in one of several optional ways.This washer may be a double washer 304 having a first annulus 306through which the screw 300 is inserted as it is attached to theclavicle and a second annulus 308 through which the suture(s) may bethreaded and then tightened during the surgery. The double washer 304may be made from any suitable medical grade material for permanentimplantation into the patient's body. As an alternative, a washer 310may be secured to the screw 300, such as with a suture 312 swaged ontothe screw 300 so that as the screw 300 is secured the suture 312 remainsexposed to support the washer 310 and is not crimped or otherwise hasits integrity affected through tightening of the screw 300. In yetanother embodiment, the head 314 of the screw 310 may have an annularflange 316 which may engage the annulus 306 to squeeze it between theflange 316 and the surface of the clavicle, thereby providing what isbelieved to be a more secure positioning of the washer 304 and itsannuluses 306, 308 relative to the clavicle. With either of theseembodiments, the washer 310 or second annulus 308 may be crimped tocapture the suture 120 after it is passed therethrough and fix thesuture in place, as desired. Another feature of the bone anchor 156 maybe to include a set screw or cam 318 within the second annulus 308 whichmay be tightened to internally clamp or capture the suture(s) 120 withinthe second annulus 308. With the set screw or cam 318 feature, thesuture(s) 120 may be readily adjusted during, and even after the surgeryto achieve the desired patient results. The needle (for example needle140 as used in the RAFT procedure) may have a suture 120 swaged to anend thereof and a bone anchor 156, such as one of the washers 302, 304,swaged to the other end of the suture 120 to thereby provide aconvenient assembly or surgical tool 320 for a surgeon to perform theRAFT procedure or other surgical procedure, thereby saving the time andtrouble of the surgeon attaching these elements together during surgery.

FIG. 20 depicts a tissue dissector 160 and tissue rasp 162. The tissuedissector 160 comprises a relatively long, thin rod 164, solid orhollow, characterized by a series of points or ridges or cones 166.Alternatively, a more aggressive dissector 160 could include shark finlike winglets 168 or other more aggressive cutting structures. The rod164 could be spatulated or round, and would preferably have a rounded,non-cutting tip 170. The tissue dissector preferably has an active end172 and a passive or non-acting central portion 174 and a thickness ofbetween about 1 mm to about 3.5 mm. The tissue rasp 162 has a thinpreferably metal rod or hollow cannula 176 with a series of rasp-likegrooves 178 oriented in various directions, as desired to achieve whatmay be generally considered as a more aggressive surface than a tissuedissector's active end 172. The grooves 178 could be oblique,orthogonal, or otherwise, and of different and varying depths to achievethe desired degree of aggressiveness. The tissue rasp 162 has an activeportion 180 containing the grooves 178 and an inactive portion 182. Asexplained above, these are similar surgical tools but generally the raspis intended to provide a more aggressive abrading surface, while thetissue dissector is intended to provide more of a cutting or nickingeffect on taut connecting tissues.

FIG. 20( a) depicts the working or active ends 172, 180 ofrepresentative tissue dissectors 160 and tissue rasps 162. For example,in one view depicted in FIG. 20( a) a tissue dissector 160 has a seriesof shark fin like winglets 168 arranged with their cutting edges inopposite directions to provide a cutting action in both directions asthe surgeon moves the tissue dissector in and out and along a tissueplane. These shark fins 168 are also shown oriented at 90° about thecircumference of the spatulated, active end 172. A tissue rasp 162 isdepicted having a generally cylindrical shape, with circular crosssection, and having a series of teeth 179 extending generally radiallyfrom its surface. These teeth can be formed in a myriad of shapes andsizes, with sharp or blunt ends; with hooks or not, or otherwise toobtain the desired results during use. A second rasp 162 is also shown,similar to that depicted in FIG. 20, to again illustrate the myriad ofgroove shapes, depths, and arrangements that can be provided to achievethe desired aggressiveness depending on its intended use.

The tissue mesher 190 is shown in its various embodiments in FIG. 21-28.As shown in FIG. 21, three rectangular blocks 192 may be securedtogether with a pair of threaded rods and wing nut fasteners 194. Amatrix of cylindrical holes 196, shown in a 2×4 pattern in FIG. 21, areformed between the blocks and each of which receives and clamps e.g. ahypodermic needle 198 with a sharp, cutting edge point 200. The needlescould alternatively be sharpened rods, or other similar cutting pointedinstruments, either hollow or solid. This embodiment of the tissuemesher 190 allows the cutting points to be positioned at differentdepths which provide for creating a three dimensional or two dimensionaltissue block, as explained, supra. As shown in FIG. 22, the tissuemesher 190 may be provided with different matrices in essentially thesame multi-block, fastened structure. As depicted, a six block 192matrix of nineteen holes 196 may be readily formed for clamping cuttingpoints at varying, or the same, depth. In order to provide forcontrolled lateral translation of the cutting points, as depicted inFIG. 23 a tissue mesher 190 similar to those already described may beslidably mounted to a pair of cross rails 202 secured at their ends 204with a pair of support rods 206. When lateral movement is desired tomake the incisions, the mesher 190 is first pressed against the dermisdesired to be treated and then slid along the rails 202. FIG. 24-26depict variations of swivel or articulated couplings 208 which may besimilarly used to mount the tissue mesher and provide for controlledmovement of the sharp cutting points (not shown) to create the desiredincisions. FIG. 27-28 depict rack and pinion arrangements 210 also forachieving controlled lateral translation of the tissue mesher.

Various of the foregoing inventions may be provided in a surgical kit,for single use or as a reusable kit, for a surgeon to purchase andperform one of the surgical procedures described herein. The inventorcontemplates that as these inventions are commercialized various ones ofthese instruments will be found to be included in one or more kits, aswell as which variations of the individual instruments from amongst thealternative embodiments described herein. Thus, the inventions are notconsidered as being limited to the described embodiments but insteadshould be limited solely by the metes and bounds of claims as they aredrafted and presented in a non-provisional application claiming priorityto this provisional application.

Use of a number of these inventions will now be explained in the contextof the RAFT breast augmentation/reconstruction procedure, and byreference to FIG. 29( a)-(g); and FIG. 30-32.

A—Design of the Arc of Abdominal Anterior Thoracic Tissue to be PurseStringed and Advanced:

Depending upon the abdominal tissue laxity and the amount of tissuerequired for the reconstruction, up to a 12 cm wide arc of upperabdominal/lower thoracic tissue can be mobilized and brought up to forma breast or to augment a pre-existing one. The pattern of the pursestring arc determines the tissue that will be advanced. This arc isoutlined on the patient skin prior to the surgery. See FIG. 29( a).

The arc that will be purse stringed and advanced cephalically starts atthe medial end of the inframammary fold (or where the inter-mammary foldstarts), then continues caudally and laterally up to a level justanterior to the mid axillary line to extend back up cephalically at thelevel of the lateral end of the inframammary fold, or what is morecorrectly referred to as the end of the lateral mammary fold. The threadloop will be passed from the clavicle in a deep plane over the bonysternum up to the beginning of the arc. Along the course of the arc, thesuture is kept subcutaneous or intra-dermal. Keeping an even level ofneedle passage is considered important by the inventor in order to avoidaccordion curtain like irregular folds as the purse string is tightened.At the lateral end of the arc, the suture dives deep again into thesubcutaneous tissue and is advanced medially and cephalically to closethe loop up at the starting point at the level of the clavicle.

B—Passing the Looped Thread:

The passing of the suspension suture is the cornerstone of thisprocedure. This is where the “J” shaped needle invention disclosedherein is put to good use. It preferably is long enough to reach fromthe clavicle to the upper abdomen with enough shaft length left tohandle and guide it. The curvature is like a double “J” and it ispreferably rigid to be driven for such a long distance while malleableenough to be steered through the tunnel it slices longitudinally throughthe dermis with its sharp cutting edges. Maintaining an even depth ofthe needle as it courses through the preferred immediate subdermal planeis preferable. To that effect, special design of the cutting tissuedissecting tip might be required such as fins or ailerons. When thesutured is pulled, passages that are too superficial will lead todimpling or puckering of the skin and passages that are too deep willlead to ridging. Since the desired result is an even line fold, it ispreferred to stay in the same plane throughout the suspension arc.Alternatively, more than one suture may be passed such that any ridgesleft by deeper passes of the first suture are captured and brought downto create an even fold.

After making a small slit on the anterior chest wall just under theclavicle, (the level of the clavicular bone anchor) two strong needleholders are required to stepwise advance the needle. See FIG. 29( a).Though two strong, pliers like, needle drivers are currently used, theinventor conceives of a handling device that can effectively grab theneedle and drive it down along its long downward spiral passage as itfollows the spiral down contour of the sternum to emerge subcutaneouslyat the level of the breast. The needle tip is first allowed to exit at apoint along the previously marked arc, just below the intermammary foldlevel. See FIG. 29( b). If this hole has been “matured” by liposuction(see below the dissecting of the abdominal apron section), then theneedle used does not need to be double pointed. (A long needle such asthis one is easier and safer to handle if it is not pointed on bothends.) Holes that have been “matured” by previous repeated cannulapassage have loose and destroyed subdermal fibers such that an in andout passage of the needle through the same hole has little chance ofcatching intact fibers and therefore will not dimple down the skin whentightened.

The needle is then passed in the deep dermal/subcutaneous tissue alongthe pre-marked arc, coming in and out as necessary through the previousliposuction puncture holes till the end of the mammary fold, in thelateral chest at about the mid-axillary line and the third to fourthintercostal space. See FIG. 29( c)-(f). This last puncture wound is theposition of the end of the lateral mammary fold and from there on, thecourse of the needle comes deep, it could pierce the pectoralis orcourse along the anterior axillary fold to emerge anteriorly through theoriginal subclavicular incision and complete the loop. See FIG. 29( g).

Pulling cephalically on this suspension loop advances the upperabdominal tissue to the breast area and the purse string effectmushrooms it into a breast dome. See FIG. 30-32. The inferio-lateralportion of the thread in the subcutaneous tissues defines theinframammary and lateral breast folds. Anchoring the loop to theclavicle and tightening it advances the abdominal and lateral thoracicflaps to create a breast mound with new inframammary and lateral breastfolds. See FIG. 29( g).

Inserting an implant is one of the alternatives to provide volume.However, lipofilling the mobilized tissue is often the preferredalternative, using one of my patented techniques and devices. Oftentimesthese are combined.

C—Dissecting the Abdominal Apron and Mobilizing it:

This is actually the first step of the procedure. It consists oftumescent liposuction of the abdominal apron through 3-8 14G needlepuncture wounds along the previously marked upper abdominal arc with themost lateral puncture at the mid-axillary line, 3^(rd) to 4^(th)intercostal space (where the lateral mammary fold would naturally end).We make a few additional puncture wounds for liposuction cannula entryaround the mid abdomen, the umbilicus and the lower abdomen. Thecriss-crossing of the cannula tunnels loosen the abdominal wall fibersto a certain extent. Then, through these same puncture wounds, using aspecial dissecting cannula (as described above), we mobilize theabdominal apron and the postero-lateral thoracic flap.

D—Re-Orienting the Fibers, Deepening the Fold and Relieving theAbdominal Tightness:

To further define the fold and create the natural overhang of apendulous breast, the fibers that prevent the bulging and mushrooming ofthe tissue on the inner side of the purse string loop need to bedivided. As described before, these fibers have to be divided in astaggered fashion with different fibers cut at different levels togenerate an inter digitating expansion. Tissue meshers help re-orientthe fascia fibers, relieve tension and eliminate unwanted folds.Dividing the stretched nerves is also achieved. Because pulling orstretching or strangulating sensory nerves causes severe pain, it isalso important to avoid grabbing cutaneous sensory nerves in the loop.On the other hand simply dividing the nerves as is done during mostoperative procedures might lead to some decreased sensation of theterritory of the nerve but usually causes no pain. The staggered meshingtherefore also serves to cut the nerves and avoid the nerve pain.

E—Tightening the Skin where Needed:

Tightening of the skin may be achieved with the tissue file and raspdescribed herein with the post dissection redraping, scarring andcontraction maintained with the help of an external adhesive supportivesplint and/or internal sutures.

F: Post on Care Wearing the External Moldable Splint

To complete the treatment, an external splint is applied, which can beformed with transparent surgical tape, an elastic mesh tape or asupportive brassiere otherwise constructed specially for this purpose,to hold the reconstructed breast in position and shape. After a fewweeks, the splint may be removed and the patient has achieved thedesired result.

As shown in FIG. 33 (a)-(c), the tissue dissectors and rasps disclosedherein may be themselves used, along with the transparent orinconspicuous easy to conceal and wear resistant bra, to perform abreast lift without surgical incisions typified by prior art procedures.For example, a woman suffering from ptosis of the breast, as depicted inFIG. 33 (a), as is well known, has a sagging breast with the breast 400being comprised of glandular tissue 402 surrounded by fat 404 all ofwhich is connected. In this procedure, the breast 400 is first inflatedwith a suitable fluid such as fat and epinephrine containing physiologicsolution to become tumescent which tightens the connecting tissue, andthen tissue dissectors 160 are used to cut the connecting tissue betweenthe fat 404 and the glandular tissue 402 to create a space 406, asdepicted in FIG. 33 (b). Several small dissector entry openings 408 arecreated in unobtrusive locations to be able to extend the tissuedissector 160 around the glandular tissue 402 and reach and cut most ifnot all of the connecting tissue. After separation, a tissue rasp (notshown) is inserted through these same openings 408 and the glandulartissue is abraded or irritated/inflamed to incite the desired scarring.Then the breast is lifted into its desired final position and shape,either manually or by use of a small suture to support the breast orwith the patient laying on her back, and a preferably transparent bra410 is applied preferably during this breast moving/shaping processwhich, when the breast reaches its final position preferably becomesadhesive to the breast and also above the breast and perhaps as high asthe clavicle, or around the shoulder as bra straps to hold it in itsdesired final position and shape. The supportive bra can come inpre-determined shapes with a protective sheet for the adhesive layer orcan be applied as multiple pieces or strands that overlap andinterdigitate to reach the desired shape and support. The breast 400 isthen held in position, as depicted in FIG. 33 (c), for a somewhatextended time period, perhaps a few or even up to six weeks, while thetissue scarring forms in sufficient rigidity to hold the breast in placewithout the bra. After achieving the formation of the supporting scartissue, the bra 410 may be removed (might use the help of an adhesiveremover) and the patient is finished with the process having achieved asuccessful breast lift. The inventor contemplates that this bra 410 ispreferably transparent so that the underlying skin tissues may beexamined to ensure no complications. Alternatively could be skin coloredfor better concealment. Also, the bra may be made of a sheet or meshfiber, or elastic weave, that would be pliable upon application and thencould be fixed, for example such as by adding a rigidifying layer orspraying a fixative thereon, to hold it in place. The bra could be madeof thin cotton or silk fabric that would cure, could be pre-formed orcut into shape during or before surgery to suit the particular patient'sphysique. Although depicted and explained as a breast lift, this samemethod is envisioned by the inventor as being suitable for other tissueengineering applications such as body lifts, tummy tucks or face lifts,for example.

As shown in FIG. 34, a shuttle needle 520 is inserted through a grommet522 inserted into a hole 524 in a bra 526 created by the needle 520 asit is passed through the bra 526 at points 527 marked along the bra 526in a pattern, and with the bra 526 preferably adhered but at least closefitting to a breast 528. The shuttle needle 520 is used to form thebasket weave (see below) within the breast 528, as explained in greaterdetail below. The shuttle needle 520 generally is formed in a curve withtwo ends 530 and a centrally located eye 532 through which one or morethreads 534 are passed for weaving a supporting basket weave inside thebreast 528. Although the inventor discloses a shuttle needle 520 as hispreferred embodiment, other needles may be used so long as care is takento loop the thread 534 and form the basket weave. Furthermore, theneedles disclosed and described above may also be used, keeping in mindthe teaching of this specification. FIG. 35 depicts an alternate designfor a grommet 522 and which includes a shoulder 536 to better hold thegrommet 528 in place in the bra 526 and prevent the needle 520 ortensioning of the thread 534 by continued weaving from inadvertently andprematurely pulling the thread 534 back inside the breast 528. FIG. 36depicts the basket weave 538 which is formed inside the breast throughuse of the kit 540 of the invention, as explained below. Although theinventor prefers the interlocking basket weave construction depicted inFIG. 36, in would be understood by those of skill in the art that otherpatterns could be used to like effect and even specialized weaves toaddress and correct particular construction issues in a patient. FIG. 37depicts the basket weave 538 inside the breast 528 to give a better ideaof the relative size, location and spacing of the inventor's preferredbasket weave 538. FIG. 38 depicts the shuttle needle 520 with its twoends 530 and centrally located eye 532. Also depicted are two sets ofgraduations 542 which are used by a surgeon as a guide and indicator asto the relative position of the needle inside the breast as the basketweave 538 is created. FIGS. 39 and 40 depict the shuttle needle 520passing through the breast parenchyma as desired to anchor the basketweave 538, as explained below.

The kit described above is preferably used to surgically constructsubcutaneously the “internal brassiere” as next described.

Technique for Use of the Kit 1—Preparation of the Breast:

The procedure preferably starts with tumescent diffuse injection of thesubcutaneous tissue with dilute lipoaspirate containing adrenaline. Thefluid in the injected dilute fat graft distends the subcutaneous planemaking it easier to dissect while the fat grafts provide fill and glue &are a source of regenerative factors. While the procedure can beperformed without fat injection, only with tumescent fluid containingadrenaline, the inventor prefers to add fat grafts or other regenerativereagents such as allograft preparations as most women also desire someadditional volume augmentation. Furthermore, the inventor is aware ofthe regenerative properties of fat grafts and their ability to helpcorrect contour defects.

Subcutaneous dissection of the skin away from the breast parenchymaallows the crucial re-draping of the skin over the breast parenchyma asthe mastopexy will ultimately hold thanks to this re-draping and to thehealing interface created by the dissection. This dissection ispreferably done with a special cannula through a number ofcircum-mammary and circum-areolar needle puncture sites. This subdermalabrasion performed in this stage also in itself causes deep scarring andretraction of the stretched out skin.

Kit Components Used: A standard liposuction—dissecting injection cannulamay be provided as part of the kit, but may also be readily available tomost plastic and reconstructive surgeons and thus not provided as partof the kit.

2—Placement of Bra:

With the patient sitting as upright as possible on the operative table,nice fitting brassiere is preferably applied that restores the desiredshape and position of the nipple areola complex. Once the ideal breastshape is reached, the breast is preferably suspended to the shouldersand the bra is preferably made to harden and stick to the skin such asby applying a hardening/gluing biocompatible material.

Kit Components Used: A sterile mesh fabric or initially stretchablematerial that can be formed into a nice fitting and supportivebrassiere. A glue-like biocompatible compound that is preferablyincorporated in the fabric, and which sticks & hardens. A bra thatpreferably stays semi-transparent with rubbery/plastic consistency witha pattern of thread weave preferably marked on the bra.

3—Weaving the Threads:

Through a small, approximately 0.5 cm incision at the clavicle, a boneanchor is inserted and through that same incision is passed the shuttleneedles and threads. The needle preferably follows the weaving patternoutlined on the bra and a grommet/sleeve is preferably inserted at eachneedle exit/entry site. A small loop of thread is left outside (with aseparate thread or small pin to prevent retraction of that loop as thethread continues to be weaved).

The depth of the sleeve/grommet is preferably adjusted to ensure thatthe thread weaves a brassiere mesh in the deeper tissues and does notgrab the dermis and subdermal tissue.

The grommet/sleeve device has been found to permit the weaving of theInternal bra. They insure that dermal fibers are not inadvertentlycaught as the needle comes in and out. The thread loops left outsideallow the interlacing of the separate threads to create a weave that isthen pulled deep inside as the threads are brought snugly together andthe grommets are removed.

A total of 6-12 threads are preferably used depending upon the size ofthe breast, the degree of ptosis and the consistency of the breast(fatty loose breasts require more loops than the more parenchymal denserfirmer breasts).

Kit Components Used: A long sharp curved needle (preferably shuttletype) which may be passed with a heavy needle holder. Grommets/needlesleeves, that stick out of the hardened conforming adherent bra toensure that the weave is kept in the deeper tissues and that it is thedeeper tissues that are suspended. Threads (preferable to have eachthread color coded to follow its weave pattern and to couple themtogether at the time of tying). Threads non-resorbable (preferably use#1 Prolene). However a fascia/collagen based allograft or syntheticmaterial that could regenerate tendon might also be preferable dependingon the surgeon and the patient.

4—Completing the Suspension.

The threads are pulled with the same even gentle tension on all threads.It is considered important not to tighten too much but rather to justpull them snug to where there is no laxity in the thread. The threadshould hold the position given to it by the bra.

The rigid adherent bra is considered important as it preserves andensures the proper shape and prevents indents and unevenness in thebreast. The contour of the breast has been found to be uneven if theloops do not have the proper length.

The inventor has found that the variable that perhaps is the mostimportant is the length of the individual thread loops. This isdetermined by tying the knot or crimpling together the two ends of thethread. The supporting bra is the device that adjusts this variable. Itinsures that virtually the exact loop length is reached when the twoends are just snug while supported by the bra and not too tight so thatthe skin dimples inside the bra. This is the rationale behind having thebra device become rigid and adherent to the skin.

The transparent/translucent property of the bra allows inspection toensure that the skin has not separated/unstuck itself from the bra if aloop is tied too tightly. Without this static support it would probablybe difficult to get the exact tension on each one of the individualthread loops as they are tied/crimpled together. The Bra further ensuresthat the support is not dependent on the sutures—no dimples—no dermis orsubdermis caught in the sutures and that we achieve an even suspensionof the deeper tissues, allowing the dissected off skin to passivelyredrape.

A preferred alternative to tying the individual thread is a device thatcan crimple/lock them all together in one step. This also avoids havingmany sutures bulked together under the clavicle.

Kit Components Used: Crimpling/locking tool/device that connects all thethreads together to the clavicle anchor.

5—Final Stage/Post Op Dressing:

Remove the adherent Bra and grommets. Simply close the small clavicleincision and inject some fat around the crimple site to camouflage thethread.

Apply a tagaderm type adherent dressing that supports the breast andimmobilizes it for a few days to a couple of weeks till the repositionedskin heals in the desired position.

Other Additional Features:

-   -   1—Array of needle tips inserted through non-scar inducing tiny        punctures selectively divide the vertical fibers that are under        tensed by the forced advancement of the superficial tissue        layers. The cuts are discrete and are at different levels such        as to open no tissue plane and leave no cavities as the tissue        advances.    -   2—Belt like locking device consisting of two or more holes on a        small band. The device is connected to the bone anchor. The        holes might have winglets for added directional grabbing        ability. The threads having completed the purse-string loop are        inserted through the holes through a simple passage or a back        and forth loop such that the tension can be adjusted and the        sutures locked into place. Additionally, the device can be        crimpled tight for a more secure hold; 1—outer cortex of the        bone; 2—bone anchor inserted in the bone; 3—connector between        anchor and locking device; 4—belt-like ring locking device that        can also be crimpled for better locking strength; 5—threads        having completed the purse-string suspension loop. See for        example the embodiment depicted and as described above in FIG.        44.    -   3—Belt like locking device consisting of two or rings. The        device is connected to the bone anchor. The threads having        completed the purse-string loop are inserted through the loops        with back and forth loops such that the tension can be adjusted        and the sutures locked into place. Additionally, the device can        be crimpled tight for a more secure hold; 1—outer cortex of the        bone; 2—bone anchor inserted in the bone; 3—connector between        anchor and locking device; 4—washer slit winglets to        directionally grab suture; 5—belt-like locking device that can        also be crimpled for better locking strength; 6—threads having        completed the purse-string suspension loop. See for example the        embodiment depicted and as described above in FIG. 43.    -   4—Alternative design of the “J” needle used for the RAFT        procedure. The cutting sharp end of the needle has triangular or        as shown has quadrangular winglets that facilitate maintaining        the same plane of penetration along the tissue. The sharp        pointed tip rapidly assumes a cross like configuration in cross        section to eventually resume the rounded cross section of the        needle shaft at the end of the long bevel. Inserts show the        cross section at multiple levels. See for example the embodiment        depicted and as described above in FIG. 45.    -   5—Design of needle with an eye that allows it to grab a suture        loop or segment. A-key chain like spiral loop where the thread        loop can be fed to end up locked inside the needle. 1 thread        entrance site. B—slit gap that can be spring loaded to insert        the suture loop into the eye of the needle. 2—thread entrance        site. See for example the embodiment depicted and as described        above in FIG. 42.

The principal advantages and features of the several related inventionshave been disclosed and described illustratively in the preferredembodiments. However, as would be understood by those of skill in theart, the inventions are not limited to these illustrative embodimentsand instead the inventor intends that the scope of his inventions belimited solely to the scope of the claims appended hereto, and theirlegal equivalents.

1-39. (canceled)
 40. A surgical method, comprising: cutting, at a firstlocation, a plurality of anchoring fibers that restrict movement of atissue region without excising the tissue region from a body, whereinthe plurality of anchoring fibers are cut along multiple planes; andrelocating at least a portion of the tissue from the first location to asecond location, different than the first location, without excising theportion of the tissue region from the body.
 41. The method of claim 40,wherein cutting the plurality of anchoring fibers includes cutting aplurality of cutaneous perforator nerves.
 42. The method of claim 40,wherein cutting the plurality of anchoring fibers expands the tissueregion.
 43. The method of claim 40, wherein the first location is anabdomen of a mammal.
 44. The method of claim 40, wherein the secondlocation is a breast of a mammal.
 45. The method of claim 40, whereinrelocating at least a portion of the tissue region includes stretchingthe portion of the tissue region from the first location to the secondlocation.
 46. The method of claim 45, wherein the first location is anabdomen of a mammal and the second location is a breast of a mammal. 47.The method of claim 40, wherein cutting the plurality of anchoringfibers includes inserting a plurality of needles into the tissue regionat least twice.
 48. The method of claim 40, wherein cutting theplurality of anchoring fibers includes inserting a plurality of needlesinto the tissue region.
 49. The method of claim 48, wherein theplurality of needles are inserted percutaneously.
 50. The method ofclaim 48, wherein the plurality of needles are part of a disposableneedle array.
 51. The method of claim 50, wherein the disposable needlearray is mounted on a cartridge.
 52. The method of claim 50, wherein thedisposable needle array includes at least 3 needles and fewer than 20needles.
 53. The method of claim 40, further comprising augmenting abreast of a mammal.
 54. The method of claim 40, further comprisingplacing the tissue region under tension before cutting the plurality ofanchoring fibers.
 55. The method of claim 40, further comprising cuttingthe plurality of anchoring fibers to produce a plurality of gapsapproximately 2 mm in diameter in the tissue region.
 56. The method ofclaim 55, further comprising grafting at least one of tissue droplets,fat, platelet rich plasma, growth factors, tumescent fluid, or stemcells into at least one of the gaps.
 57. The method of claim 40, whereinthe plurality of anchoring fibers in the tissue region are cut to aratio of up to about 20% with respect to uncut anchoring fibers in thetissue region.
 58. The method of claim 40, wherein the plurality ofanchoring fibers in the tissue region are cut to a ratio of betweenabout 20-30% with respect to uncut anchoring fibers in the tissueregion.
 59. A method of cutting tissue in a body of a patient,comprising: applying tension to the tissue; at least partially insertingan array of needles into the tissue; selectively cutting a plurality offibers that are configured to hold the tissue in place; at leastpartially pulling the array of needles out of the tissue; andre-inserting the array of needles into the tissue, wherein the fibersare cut at different depths to expand the tissue, and wherein insertingand re-inserting the array of needles creates a region of tissue with aplurality of punctures.
 60. The method of claim 59, wherein each of theplurality of punctures is approximately 2 mm in diameter.
 61. The methodof claim 59, wherein only tensioned fibers are cut.
 62. The method ofclaim 59, wherein inserting the array of needles includes inserting thearray of needles into the region of tissue such that the needles do notpass completely through the tissue.
 63. The method of claim 59, furthercomprising relocating at least a portion of the region of tissue withthe plurality of punctures to augment a breast.
 64. The method of claim59, wherein the array of needles is mounted on a disposable cartridge.65. The method of claim 59, wherein the array of needles is insertedpercutaneously into the region of tissue.
 66. The method of claim 59,wherein the array of needles is mounted on a handling device.
 67. Themethod of claim 59, wherein the plurality of anchoring fibers are cut toa ratio of at least about 20% with respect to uncut anchoring fibers inthe region of tissue.
 68. The method of claim 59, wherein the pluralityof anchoring fibers are cut to a ratio of between about 20-30% withrespect to uncut anchoring fibers in the region of tissue.
 69. Asurgical method, comprising: percutaneously inserting a needle arrayinto body tissue to cut a plurality of anchoring fibers in a region ofthe body tissue without excising the region of tissue, wherein theplurality of anchoring fibers are configured to restrict movement of theregion of tissue; at least partially pulling the needle array out of theregion of tissue; re-inserting the needle array into the region oftissue to cut the plurality of anchoring fibers along multiple planes tocreate a plurality of offset punctures in the region of tissue; andrelocating at least a portion of the region of tissue from the firstlocation to a second location, different than the first location, whilethe region of tissue remains attached to the body.
 70. The method ofclaim 69, wherein the first location is an abdomen and the secondlocation is a breast.
 71. The method of claim 69, wherein the needlearray is mounted on a handling device and includes at least 3 needles.72. The method of claim 69, wherein each of the plurality of offsetpunctures created is approximately 2 mm in diameter.
 73. The method ofclaim 69, wherein the method further comprises grafting at least one oftissue droplets, fat, platelet rich plasma, growth factors, tumescentfluid, or stem cells into at least one of the plurality of offsetpunctures.
 74. A method of augmenting a breast, comprising:percutaneously inserting a needle array into abdominal tissue to cut aplurality of anchoring fibers that restrict movement of the abdominaltissue without excising the abdominal tissue from a patient's body; atleast partially pulling the needle array out of the abdominal tissue;re-inserting the array needle array into the abdominal tissue to cut theplurality of anchoring fibers along multiple planes to create aplurality of offset punctures in a region of the abdominal tissue;relocating at least a portion of the region of abdominal tissue to thebreast, while the region of abdominal tissue remains attached to thebody; and augmenting the breast with at least a portion of the relocatedabdominal tissue.